Method for treatment of diarrhea-predominant irritable bowel syndrome

ABSTRACT

The present invention provides methods for treating diarrhea-predominant irritable bowel syndrome comprising administering to a patient in need thereof, an inhibitor of chloride-ion transport in an amount sufficient to treat diarrhea-predominant irritable bowel syndrome (d-IBS). Treatment of d-IBS includes the treatment of the diarrhea component of d-IBS as well as the pain, abdominal discomfort and other symptoms associated with d-IBS. In one embodiment, the inhibitor of chloride-ion transport is crofelemer.

BACKGROUND OF THE INVENTION

Irritable bowel syndrome (IBS) is a common functional disorder of the bowel that has a pronounced effect on quality of life. A defining characteristic of IBS is abdominal discomfort or pain. The Rome II Diagnostic Criteria (a system for diagnosing functional gastrointestinal disorders based on symptoms) for IBS is as follows: at least 12 weeks or more, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that is accompanied by at least two of the following features: (1) it is relieved with defecation, and/or (2) onset is associated with a change in frequency of stool, and/or (3) onset is associated with a change in form (appearance) of stool.

Other symptoms that support the diagnosis of IBS include pain; abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); passage of mucus; and bloating or feeling of abdominal distension. Patients can be sub-divided by their underlying bowel habits: (i) diarrhea-predominate IBS, (ii) constipation-predominate IBS, and (ii) constipation alternating with diarrhea (alternating IBS).

The pathophysiology of IBS is poorly understood despite the fact that about a quarter of the population in the UK may exhibit the symptoms, and approximately 15 percent of U.S. adults report symptoms that are consistent with the diagnosis of IBS. It is estimated that only 25 percent of persons with IBS seek medical care. In addition, patients diagnosed with IBS are at increased risk for other, non-gastrointestinal functional disorders such as fibromyalgia and interstitial cystitis.

IBS is the most common diagnosis made by gastroenterologists in the U.S., and accounts for 12 percent of visits to primary care providers. Approximately $8 billion in direct medical costs and $25 billion in indirect costs are spent annually in the U.S. for diagnosing and treating IBS. Thus, IBS accounts for a large proportion of annual healthcare costs in the U.S.

Primary treatment of IBS involves counseling and dietary modification. Drug therapy is considered to be beneficial if directed at individual symptoms. For diarrhea predominant cases, antidiarrheal drugs such as loperamide can be used, which treat diarrhea, but not abdominal pain. Since abdominal pain is one of the defining characteristic of IBS, anti-diarrheal drugs do not adequately treat IBS (Jailwala et al., 2000, Ann Intern Med. 2000;133:136-147; Cremonini et al., 2004, Minerva Med 95:427-441). For constipation predominant cases, ispaghula is often used to increase dietary fiber. Where patients have pain and distension as predominant symptoms, anti-spasmolytics are commonly used. Mebeverine and peppermint oil are often used in such cases. Other agents that have been tried for treating IBS include beta-blockers, naloxone, ondansetron, calcium channel blockers, simethicone, leuprorelin, octreotide and cholecystokinin antagonists with variable results (Martindale, The Extra Pharmacopoeia, 31st Edition (1996) p. 1197).

Alosetron hydrochloride, Lotronex® (GlaxoSmithKline, Reserarch Triangle Park, N.C.), a selective 5-hydroxytryptamine 3 (5-HT₃) antagonist is currently the only drug approved for treating females with severe diarrhea-predominant irritable bowel syndrome (d-IBS). Due to safety concerns, including ischemic colitis and severe, life threatening constipation, even this one drug is approved for use only in women with severe d-IBS. Although there are other drugs for the treatment of diarrhea (e.g. loperamide, diphenoxylate), such drugs do not address the multiple symptoms of d-IBS including pain and abdominal discomfort and, thus, are not long-term options. (See Wood, 2003, AJJ. NEMJ 349: 2136-2146). There is a need for improved therapeutics for the treatment of d-IBS that address the multiple symptoms of d-IBS including pain and abdominal discomfort.

U.S. Pat. Nos. 5,211,944 and 5,494,661 to Tempesta disclose the use of a proanthocyanidin polymeric composition isolated from Croton spp. or Calophyllum spp. for the treatment of viral infections. Rozhon et al., U.S. Patent Publication No. 2005/0019389, disclose the use of a proanthocyanidin polymeric composition isolated from Croton spp. or Calophyllum spp. for the treatment of secretory or traveler's diarrhea. Di Cesare et al., 2002, Am J Gastroenterol 10:2585-2588 disclose a clinical trial of crofelemer as a treatment for traveler's diarrhea compared to placebo. Dosages used in this study were 500 mg/day (125 four times a day); 1000 mg/day (250 mg four times a day); and 2000 mg/day (500 mg four times a day) for two days. The study showed that the composition was useful for the amelioration of stool frequency and gastrointestinal symptoms in patients with traveler's diarrhea.

Citation or identification of any reference in this section or any other section of this application shall not be construed as an admission that such reference is available as prior art for the present application.

SUMMARY OF THE INVENTION

The present invention relates to methods for treating at least one symptom of diarrhea-predominant irritable bowel syndrome (d-IBS) by administering a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule). Exemplary inhibitor molecules are those that inhibit secretion of chloride ions through the cystic fibrosis transmembrane conductance regulator chloride-ion channel (CFTR). Other exemplary inhibitor molecules include potassium ion channel openers. Exemplary symptoms of d-IBS include pain, abdominal discomfort, diarrhea, abnormal stool frequency, abnormal stool consistency and the presence of urgency. Thus, in one embodiment, the invention provides a method for the treatment of one or more symptoms of d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the one or more symptoms of d-IBS. In preferred embodiments, the dosage of the inhibitor molecule is bioequivalent to orally administered enteric coated crofelemer at a dosage of about 50 mg per day to about 750 mg per day. In one embodiment, bioequivalency is a sufficient dose of an inhibitor molecule to produce a similar therapeutic effect as seen with another inhibitor molecule at a particular dosage, e.g., crofelemer at a dosage of about 50 mg per day to about 750 mg per day. In another embodiment, bioequivalency is as defined by, or is as determined in accordance with methods approved by, the U.S. Food and Drug Administration. In a particular embodiment, the inhibitor molecule is co-administered with a compound that inhibits COX-2, and preferably selectively inhibits COX-2 over COX-1, which compound is preferably not systemically absorbed. Such compounds include 5-ASA, sulfasalazine, mesalamine, APAZA, as well as other commercially available COX-2 inhibitors such as celecoxib and rofecoxib.

In a particular embodiment, the present invention is directed to a method of treating pain and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain and diarrhea associated with d-IBS. In another embodiment, the present invention is directed to a method of treating abdominal discomfort and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort and diarrhea associated with d-IBS. In another particular embodiment, the present invention is directed to a method of treating pain associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain associated with d-IBS. In another embodiment, the present invention is directed to a method of treating abdominal discomfort associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort associated with d-IBS. Optionally, analgesic or anti-inflammatory agents can be co-administered with the inhibitor molecule. In particular, the agent is formulated or is modified such that it is not systemically absorbed.

In another embodiment, the present invention is directed to a method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the diarrhea associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer. In yet another embodiment, the present invention is directed to a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer.

In another embodiment, the present invention is directed to a method of treating diarrhea associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer (CAS 148465-45-6) effective to treat the diarrhea associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day. In yet another embodiment, the present invention is directed to a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day. In certain embodiments where crofelemer is otherwise formulated, for example, in a controlled release formulation (not enterically protected), the dosage of crofelemer administered is bioequivalent to a dosage of about 50 mg per day to about 750 mg per day of orally administered enterically-protected crofelemer.

In another embodiment, the present invention is directed to a method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the diarrhea associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer. In yet another embodiment, the present invention is directed to a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a graph illustrating the Effect of Crofelemer 125 mg bid on Stool Frequency in Females.

FIG. 2 is a graph illustrating the Effect of Crofelemer 125 mg bid on Urgency in Females.

FIG. 3 is a graph illustrating the Effects of Crofelemer on Adequate Relief of IBS Symptoms in Females.

FIG. 4 is a graph illustrating the Effect of Crofelemer on Pain Score in Females.

FIG. 5 is a graph illustrating the Effect of Crofelemer on Percent of Pain Free Days in Females.

FIG. 6 is a graph illustrating the Effect of Crofelemer on Pain Score in Females.

FIGS. 7A-7H show exemplary CFTR inhibitor molecules useful in the methods of the present invention. FIG. 7A is 3-[(3-trifluoromethyl)phenyl]-5-[(3-carboxyphenyl)methylene]-2-thioxo-4-thiazolidinone; FIGS. 7B and 7F are glycine hydrazides; FIGS. 7C, 7D, 7E, 7G and 7H are malonic acid hydrazides. As discussed, infra, these molecules can be optionally pegylated to make them non-absorbable in the intestines.

DETAILED DESCRIPTION OF THE INVENTION

The present invention relates to methods for treating at least one symptom of diarrhea-predominant irritable bowel syndrome (d-IBS) by administering a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule). Exemplary inhibitor molecules are those that inhibit secretion of chloride ions through the cystic fibrosis transmembrane conductance regulator chloride-ion channel (CFTR). Other exemplary inhibitor molecules include potassium ion channel openers. Exemplary symptoms of d-IBS include pain, abdominal discomfort, diarrhea, abnormal stool frequency, abnormal stool consistency and the presence of urgency. Thus, in one embodiment, the invention provides a method for the treatment of one or more symptoms of d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the one or more symptoms of d-IBS.

The present invention is based, in part, on the discovery that polymeric proanthocyanidin compositions isolated from Croton spp. or Calophyllum spp., for example, crofelemer, alleviate pain and abdominal discomfort associated with d-IBS. Further, the present invention is based, in part, on the discovery that chloride ion transport in epithelial cells, for example, through the cystic fibrosis transmembrane conductance regulator chloride-ion channel (CFTR), is involved not only in secretory (acute) diarrhea but also is unexpectedly involved in the etiology of diarrhea-predominant irritable bowel syndrome (d-IBS). Additionally, the present invention is based, in part, on the discovery that polymeric proanthocyanidin compositions isolated from Croton spp. or Calophyllum spp., for example, crofelemer, alleviate the diarrheal symptoms of d-IBS, such as abnormal stool frequency, abnormal stool consistency and presence of urgency, at dosages significantly less than those previously used for treating secretory diarrhea. For example, dosages previously taught to be effective in treating secretory diarrhea comprised 5,500 mg of orally administered enterically-protected crofelemer over two days, whereas exemplary dosages in the present invention comprise between about 50 mg and about 750 mg per day of orally administered enterically-protected crofelemer.

Chloride ion transport can be inhibited by a number of mechanisms. For example, chloride ion secretion can be inhibited by affecting the function of the cystic fibrosis transmembrane conductance regulator chloride ion channel (CFTR) such that chloride ion transport is inhibited. Chloride ion secretion can also be inhibited by opening potassium ion channels in a cell. Chloride-ion secretion can also be inhibited by blocking up-regulation of cAMP.

The cystic fibrosis transmembrane conductance regulator chloride ion channel (CFTR) is a 1480 amino acid protein which has been associated with the expression of chloride conductance in a variety of eukaryotic cell types. See Rommens et al., 1989, Science 245:1059; Riorden et al., 1989, Science 245:1066; Kerem et al., 1989, Science 245:1073; Drumm et al., 1991, Cell 64:681; Kartner et al., 1991, Cell 64:681; Gregory et al., 1990, Nature 347:382; Rich et al., 1990, Nature 347:358; and Rommens et al., 1991, Proc. Nat. Acad. Sci. USA 88:7500. Defects in CFTR destroy or reduce the ability of epithelial cells in the airways, sweat glands, pancreas and other tissues to secret chloride ions in response to cAMP-mediated agonists and impair activation of apical membrane channels by cAMP-dependent protein kinase A (PKA). See Frizell et al., 1987, Trends Neurosci 10:190; Welsh, 1990, FASEB J. 4:2718.

The nucleotide and amino acid sequences of CFTR have been cloned (Riordan et al., 1989, Science 245:1066-1073 and are accessible in GenBank under Accession No. M28668 and in SwissProt under Accession No. P13569, respectively.

Inhibitor molecules useful in the methods of the present invention include any molecule that inhibits chloride-ion secretion, e.g., by inhibiting the function of CFTR or by opening potassium ion channels or by inhibiting up-regulation of cAMP, thus preventing the opening of chloride ion channels. In particular embodiments, the inhibitor molecules of the invention include small molecules that are formulated as to be immobilized onto polymers to limit systemic absorption, as well as isolated naturally occurring CFTR inhibitors, potassium-ion channel openers, cAMP blockers/inhibitors and synthetic or semisynthetic forms thereof. Analogs, derivatives and modified forms of the inhibitors of the invention are also contemplated.

Many molecules are known in the art that are useful in the methods of the present invention. For example, exemplary molecule that inhibit CFTR function include sparteine (U.S. Pat. No. 5,100,647); thiazolidinone compounds such as those described, for example, in U.S. Patent Application Publication Nos. 2004-0063695 and 2004-0235800, such as 2-thioxo-4-thiazolidinone compounds and 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl)methylene]-2-thioxo-4-thiazolidinone, which is described in Thiagarjah et al., 2004, Gastroenterology 126:511-519 (see FIG. 7) or other 2-thioxo-4-thiazolidinone analogs and derivatives thereof; N-(2-naphthalenyl)-[(3,5-dibromo-2,4-dihydroxyphenyl)methylene]glycine hydrazide or other glycine hydrazide analogues or derivatives thereof (see FIG. 7); malonic acid dihydrazides or analogues or derivatives thereof (see FIG. 7); sulfonylureas such as tolbutamide, glibenclamide and related analogs as described, for example, in U.S. Pat. No. 5,234,922; fluorescein or a derivative thereof such as those described, for example, in U.S. Patent Application Publication No. 2004-0092578; and nonhydrolyzable analogs of cAMP or cGMP that inhibit, rather than activate, CFTR function such as 8-bromo-cAMP, 8-(4-chlorophenylthio) (CPT)-cAMP and 8-bromo-cGMP, CPT-cGMP.

Additional exemplary inhibitor molecules include, but are not limited to: verapamil; nifedipine; diltiazem; disulfonic stilbene compounds; arylaminobenzoates or analogs or derivatives thereof such as diphenylamine-2-carboxylate (DPC) or 5-nitro-2(3-phenylpropylamino)benzoate (NPPB) or anthracene-9-carboxylic acid (9-AC); flufenamic acid (FFA); 9-(tetrahydro-2-furyl) adenine (SQ22536); 2′,5′-dideoxyadenosine (DDA); loperamide; racecadotril; lidamidine hydrochloride; lonidamine; vanadate; bumetanide; pp2a; PP1; PP2B; bismuth subsalicylate; diphenoxylate hydrochloride; and sparteine. Additional discussion and information regarding the above compounds may be found in Fedorak et al., 1987, Digestive Disease and Sciences 32(2): 195-205; Farthing, 2004, Expert Opin. Investig. Drugs 13(7):777-785; Suzuki et al., 2003, J. Physiol. 546(3):751-763; Sullivan et al., 1996, Kidney International 49:1586-1591; Galietta et al., 2004, Curr. Opin. Pharmacol. 4:497-503. Additional discussion and examples of chloride channel inhibitors are disclosed in Greger, 1990, Methods in Enzymology 191:793-810. All of the foregoing patent and non-patent references are incorporated by reference herein in their entireties.

Inhibitor molecules of the invention also include potassium-ion channel openers such as diazoxide, lemakalim and minoxidil sulfate, as well as related analogs such as those described for example, in U.S. Pat. No. 5,234,922.

Additional exemplary inhibitor molecules include naturally occurring CFTR inhibitors and synthetic or semisynthetic forms thereof include, for example, flavonoids including, but not limited to cocoa-related flavonoids isolated from cocoa beans as described in Schuier et al., 2005, J. Nutr. 135:2320-2325; fatty acids including but not limited to, arachidonic acid, linoleic acid, oleic acid, elaidic acid, palmitic acid, myristic acid, lysophosphatidic acid, and niflumic acid; flavonols; polyphenols; proanthocyanidins; oligomeric proanthocyanidins (OPCs); procyanidolic oligomers (PCOs); tannins; condensed tannins; leukocynanidins; anthocyanidins; procyanidins (e.g., B1-B5 and C1-C2); cyanidins; prodelphinidins; delphinidins; catechins; epicatechins; gallocatechins; epigallocatechins; epigallocatechin gallate; epicatechin gallate; catechin gallate; gallocatechin gallate; quercetin; sesquiterpenes; diterpenes; terpenes and terpenoid derivatives; alkaloids; saponins; morin; luteolin; baicalein; and apigenin; and oligomers, polymers, copolymers and derivatives of any of the foregoing.

In one preferred embodiment, the inhibitor molecule is a proanthocyanidin polymer composition. In another embodiment, the proanthocyanidin polymer composition is an aqueous soluble proanthocyanidin polymer composition. In another preferred embodiment, the inhibitor molecules of the present invention are not systemically absorbed or are modified not to be systemically absorbed when administered orally.

Proanthocyanidins are a group of condensed tannins. Tannins are found in a wide variety of plants and are classified as either hydrolyzable or condensed. Many plants used in traditional medicine as treatment or prophylaxis for diarrhea have been found to contain tannins and proanthocyanidins in particular (see, e.g., Yoshida et al., 1993, Phytochemistry 32:1033; Yoshida et al., 1992, Chem. Pharm. Bull., 40:1997; Tamaka et al., 1992, Chem. Pharm. Bull. 40:2092). Crude extracts from medicinal plants, for example, Pycanthus angolenis and Baphia nitida, have been shown to have antidiarrheal qualities in animal tests (Onwukaeme and Anuforo, 1993, Discovery and Innovation, 5:317; Onwukaeme and Lot, 1991, Phytotherapy Res., 5:254). Crude extracts which contain tannins, in particular extracts from carob pods and sweet chestnut wood, have been proposed as treatments or prophylactics for diarrhea (U.S. Pat. No. 5,043,160; European Patent No. 481,396).

Proanthocyanidins are comprised of at least two or more monomer units that may be of the same or different monomeric structure. The monomer units (generally termed “leucoanthocyanidin”) are generally monomeric flavonoids which include catechins, epicatechins, gallocatechins, galloepicatechins, flavanols, flavonols, and flavan-3,4-diols, leucocyanidins and anthocyanidins. Therefore, the polymer chains are based on different structural units, which create a wide variation of polymeric proanthocyanidins and a large number of possible isomers (Hemingway et al., 1982, J. C. S. Perkin, 1:1217). Larger polymers of the flavonoid 3-ol units are predominant in most plants, and are found with average molecular weights above 2,000 daltons, containing 6 or more units (Newman et al., 1987, Mag. Res. Chem., 25:118).

Proanthocyanidin polymers are found in a wide variety of plants, particularly those with a woody habit of growth (e.g., Croton spp. and Calophyllum spp.). A number of different Croton tree species, including Croton sakutaris, Croton gossypifolius, Croton palanostima, Croton lechleri, Croton erythrochilus and Croton draconoides, found in South America, produce a red viscous latex sap called Sangre de Drago or “Dragon's Blood”. This red, viscous latex is widely known for its medicinal properties. For example, U.S. Pat. No. 5,211,944 first described the isolation of an aqueous soluble proanthocyanidin polymer composition from Croton spp. and the use of the composition as an antiviral agent (See also Ubillas et al., 1994, Phytomedicine, 1:77). The proanthocyanidin polymer composition was shown to have antiviral activity against a variety of viruses including, respiratory syncytial, influenza, parainfluenza and herpes viruses. U.S. Pat. No. 5,211,944 also discloses the isolation of an aqueous soluble proanthocyanidin polymer composition from Calophyllum inophylum and the use of this composition as an antiviral agent.

Exemplary proanthocyanidin polymer compositions useful in the present invention are preferably isolated from a Croton spp. or Calophyllum spp by any method known in the art. For example, the proanthocyanidin polymer composition may be isolated from a Croton spp. or Calophyllum spp. by the method disclosed in Example 2, infra, or disclosed in U.S. Pat. No. 5,211,944 or in Ubillas et al., 1994, Phytomedicine 1: 77-106.

In one preferred embodiment, a proanthocyanidin polymer composition of the invention is crofelemer. Crofelemer (CAS 148465-45-6) is an oligomeric proanthocyanidin of varying chain lengths derived from the Dragon's Blood Croton lecheri of the family Euphorbiaceae. Crofelemer has an average molecular weight of approximately 1900 daltons to approximately 2700 daltons. The monomers comprising crofelemer comprise catechin, epicatechin, gallocatechin, and epigallocatechin. The chain length of crofelemer ranges from about 3 to about 30 units with an average chain length of about 8 units. The structure of crofelemer is shown below.

Wherein the average n=6.

Another illustrative method for isolating crofelemer can be found in U.S. Patent Publication No. 2005/0019389, the contents of which are expressly incorporated herein.

In other embodiments of the invention, a raw latex obtained from a Croton species or a Calophyllum species or an extract obtained from a Croton species or a Calophyllum species that are not specifically polymeric proanthocyanidin compositions are useful in the methods of the present invention. Exemplary extracts are described in Persinos et al., 1979, J. Pharma. Sci. 68:124 and Sethi, 1977, Canadian J. Pharm. Sci. 12:7.

In particular embodiments, inhibitor molecules of the invention useful in the methods of the present invention are antisense oligonucleotides to the CFTR nucleotide sequence that inhibit expression of CFTR. Such antisense nucleic acids useful in the methods of the present invention are oligonucleotides that are double-stranded or single-stranded, RNA or DNA or a modification or derivative thereof, which can be directly administered, or which can be produced intracellularly by transcription of exogenous, introduced sequences. The antisense nucleic acids can be tested by known methods to confirm their ability to inhibit CFTR function by inhibiting expression of CFTR.

In certain embodiments, the CFTR antisense nucleic acids can be of at least six nucleotides and can be preferably oligonucleotides (ranging from 6 to about 50 oligonucleotides). In specific aspects, the oligonucleotide is at least 10 nucleotides, at least 15 nucleotides, at least 100 nucleotides, or at least 200 nucleotides in length. The oligonucleotides can be DNA or RNA or chimeric mixtures or derivatives or modified versions thereof, single-stranded or double-stranded. The oligonucleotide can be modified at the base moiety, sugar moiety, or phosphate backbone using techniques well known in the art. The oligonucleotide may include other appending groups such as peptides, or other compounds that inhibit systemic absorption, particularly when administered orally. The oligonucleotide may be modified at any position on its structure with substituents generally known in the art.

An RNA interference (RNAi) molecule can be used to as an inhibitor of CFTR function by decreasing expression of CFTR. RNAi is defined as the ability of double-stranded RNA (dsRNA) to suppress the expression of a gene corresponding to its own sequence. RNAi is also called post-transcriptional gene silencing or PTGS. Since the only RNA molecules normally found in the cytoplasm of a cell are molecules of single-stranded mRNA, the cell has enzymes that recognize and cut dsRNA into fragments containing 21-25 base pairs (approximately two turns of a double helix). The antisense strand of the fragment separates enough from the sense strand so that it hybridizes with the complementary sense sequence on a molecule of endogenous cellular mRNA (e.g., a human CFTR). This hybridization triggers cutting of the mRNA in the double-stranded region, thus destroying its ability to be translated into a polypeptide. Introducing dsRNA corresponding to a particular gene thus knocks out the cell's own expression of that gene in particular tissues and/or at a chosen time.

In other embodiments, inhibitors of CFTR function or expression can be aptamers of CFTR. As is known in the art, aptamers are macromolecules composed of nucleic acid (e.g., RNA, DNA) that bind tightly to a specific molecular target (e.g., CFTR). A particular aptamer may be described by a linear nucleotide sequence and is typically about 15-60 nucleotides in length. In addition to high specificity, aptamers have very high affinities for their targets (e.g., affinities in the picomolar to low nanomolar range for proteins). Selection of aptamers that can bind to CFTR or a fragment thereof can be achieved through methods known in the art. For example, aptamers can be selected using the SELEX (Systematic Evolution of Ligands by Exponential Enrichment) method (Tuerk and Gold, 1990, Science 249:505-510.

In certain embodiments, an antibody that binds to the CFTR can be used in the methods of the present invention. Exemplary antibodies to CFTR are described in WO 95/06066, the disclosure of which is incorporated herein by reference in its entirety. In a preferred embodiment, the antibody to CFTR binds to the extracellular portion of the CFTR. Methods for making antibodies to CFTR or an immunogenic fragment, preferably an extracellular fragment of CFTR are well known in the art. Once the antibody has been produced, it can be screened using known methods, supra, for determining its effectiveness in inhibiting CFTR function, such as chloride-ion transport.

According to the invention, CFTR, its fragments or other derivatives, or analogs thereof, may be used as an immunogen to generate antibodies which recognize such an immunogen for use in the methods of the invention. Such antibodies include but are not limited to polyclonal, monoclonal, chimeric, single chain, Fab fragments, and an Fab expression library. In one embodiment, antibodies to a portion of CFTR exposed on the outside of the cell are produced.

Antibody fragments which contain the idiotype of CFTR can be generated by known techniques. For example, such fragments include but are not limited to: the F(ab′)2 fragment which can be produced by pepsin digestion of the antibody molecule; the Fab′ fragments which can be generated by reducing the disulfide bridges of the F(ab′)2 fragment, and the Fab fragments which can be generated by treating the antibody molecule with papain and a reducing agent. In the production of antibodies, screening for the desired antibody can be accomplished by techniques known in the art, e.g. ELISA (enzyme-linked immunosorbent assay).

Any method known in the art that measures chloride-ion transport can be used or modified appropriately to test whether a candidate molecule can inhibit chloride-ion transport. For example, chloride-ion transport can be used to test a candidate molecule for its effect on CFTR function. An exemplary method for testing whether a candidate compound inhibits CFTR function is described in U.S. Pat. No. 5,234,922. Briefly, a candidate molecule is contacted with a cell expressing CFTR (endogenously or recombinantly), optionally with an activator of CFTR such as a cAMP agonist (e.g., CPT-cAMP, db-cAMP, forskolin, IBMX, cholera toxin, E. coli lipopolysaccharide) and whole-cell membrane currents are measured. If the current is less in the presence of the candidate molecule as compared to a cell not contacted with the candidate molecule, the molecule inhibits CFTR function. Another exemplary screening method which uses Ussing chambers to measure the chloride-mediated current is described in Schuier et al., 2005, J. Nutr. 135:2320-2325.A similar method is described in Fischer et al., 2004, J. Ethnopharm. 93:351-357. A particular high-throughput method for screening for inhibitors of CFTR function is described in Galietta et al., 2004, Curr. Opin. Pharmacol. 4:497-503.

In one embodiment, the method comprises contacting a candidate compound and an activator of CFTR function with a cell expressing CFTR, measuring the chloride-ion-dependent current produced by the cell, and comparing the current produced by the contacted cell to the current produced by a second cell contacted only with the activator of CFTR function, wherein a lower level of current produced by the cell contacted with the candidate molecule as compared to the level of current produced by the second cell indicates that the candidate molecule is an inhibitor of CFTR function. In one aspect of this embodiment, the activator of CFTR function is a cAMP agonist. In another aspect, CFTR is recombinantly expressed in the cells.

In another embodiment of the present invention, combinatorial chemistry can be used to identify agents that inhibit chloride-ion transport, such as those that inhibit CFTR function. Combinatorial chemistry is capable of creating libraries containing hundreds of thousands of compounds, many of which may be structurally similar. While high throughput screening programs are capable of screening these vast libraries for affinity for known targets, new approaches have been developed that achieve libraries of smaller dimension but which provide maximum chemical diversity. (See e.g., Matter, 1997, Journal of Medicinal Chemistry 40:1219-1229).

In a preferred embodiment, the inhibitor molecules used in the methods of the invention are not substantially systemically absorbed when administered orally. Small molecules and other drugs that are systemically absorbed when delivered orally can be modified to prevent systemic absorption. Such modifications are known in the art. For example, an inhibitor molecule of the invention such as a small molecule inhibitor may be covalently attached to a non-systemically absorbed compound that is substantially inert in the gastrointestinal tract and does not interfere with the function of the inhibitor molecule. Such non-systemically absorbed compounds include various polymers. The polymers that are preferably used with the inhibitor molecules of the invention resist degradation and absorption in the gastrointestinal system, i.e., the polymers do not substantially break down under physiological conditions in the stomach and intestines into fragments which are absorbable by body tissues. Polymers that have a non-hydrolyzable backbone which is substantially inert under conditions encountered in the gastrointestinal tract, are preferred. Such polymers will preferably have a sufficiently high molecular weight to resist absorption, partially or completely, from the gastrointestinal tract into other parts of the body. The polymers can have molecular weights ranging from about 500 Daltons to about 500,000 Daltons, preferably from about 2,000 Daltons to about 150,000 Daltons. Examples of suitable polymers include but are not limited to, polysaccharides, polyethylene glycol polymers, cellulosic polymers, polystyrene polymers, polyacrylate polymers, and polyamide polymers.

Polymer molecules that are not systemically absorbable and which are substituted by one or more of tolbutamide, glibenclamide, diazoxide, lemakalim, minoxidil sulfate, epicatechin, catechin, quercetin, morin, luteolin, baicalein, apigenin, fluorescein, 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl) methylene]-2-thioxo-4-thiazolidinone, verapamil, nifedipine, diltiazem, loperamide, diphenylamine-2-carboxylate (DPC), 5-nitro-2(3-phenylpropylamino)benzoate (NPPB), anthracene-9-carboxylic acid (9-AC), flufenamic acid (FFA), 9-(tetrahydro-2-furyl) adenine (SQ22536), 2′,5′-dideoxyadenosine, sparteine, and their derivatives, fragments and/or analogs of can be screened for inhibitory activity of CFTR function.

The present invention encompasses methods for treating and/or preventing one or more symptoms associated with diarrhea-predominant irritable bowel syndrome (d-IBS), in warm blooded animals, including male and female humans, which symptoms include, but are not limited to, pain, abdominal discomfort, diarrhea, presence of urgency, abnormal stool frequency and abnormal stool consistency. The methods of the invention generally comprise administering to a subject in need of d-IBS treatment an inhibitor of chloride-ion transport in accordance with the invention. In a preferred embodiment, the inhibitor is orally administered and is not systemically absorbed. Preferably, the patient is a human female.

In one embodiment, the present invention provides a method of treating pain and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain and diarrhea associated with d-IBS. In another embodiment, the present invention provides a method of treating abdominal discomfort and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort and diarrhea associated with d-IBS. In certain embodiments, the inhibitor molecule is co-administered with an analgesic and/or anti-inflammatory compound, such as one that inhibits COX-2 and preferably inhibits COX-2 over COX-1.

In one embodiment, the present invention provides a method of treating pain associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain associated with d-IBS. In another embodiment, the present invention provides a method of treating abdominal discomfort associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort associated with d-IBS. In certain embodiments, the inhibitor molecule is co-administered with an analgesic and/or anti-inflammatory compound, such as one that inhibits COX-2 and preferably inhibits COX-2 over COX-1.

The inhibitor molecules of the invention can be administered in a single or a divided dosage from one, two, three or four times per day. In a particular embodiment, the inhibitor molecule is administered twice daily. In yet another embodiment, the inhibitor molecule is administered twice daily for at least two consecutive days. In yet another embodiment, the inhibitor molecule is administered for at least a period of time selected from the group consisting of 24 hours, 48 hours, 72 hours, 96 hours, one week, two weeks, one month, two months, and three months. In certain embodiments, where d-IBS is a chronic condition, the inhibitor molecule is taken indefinitely.

Pain and discomfort can be measured by any method known in the art, for instance on a pain or discomfort scale in which a patient assigns the level of pain or discomfort on a scale of 0 to 5, with 0 being no pain or discomfort and 5 being assigned the highest level of pain or discomfort. In certain embodiments, the alleviation of pain or discomfort is measured by a lowering of the average level of pain or discomfort, an increase in the number of pain- or discomfort-free days. In certain embodiments, the number of pain- or discomfort-free days is increased by at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or by at least 50% compared to before treatment. In other embodiments, the level of pain or discomfort decreased by at least 0.1, 0.2, 0.3, 0.4 or by at least 0.5 units compared to before treatment.

In another embodiment, the present invention provides a method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the diarrhea associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer. In yet another embodiment, the present invention provides a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer.

In particular embodiments, stool frequency is decreased by at least 10%, 20%, 30%, 40% or 50% compared to before treatment. In other embodiments, stool frequency is decreased by at least one bowel movement per day compared to before treatment. In other embodiments, stool consistency is increased, i.e., there is a decrease in the amount of water in the stool, by at least 10%, 20%, 25%, 30%, 40%, or 50% compared to before treatment. In yet other embodiments, presence of urgency is decreased by at least 10%, 20%, 30%, 40%, or by at least 50% compared to before treatment.

In another embodiment, the present invention provides a method of treating diarrhea associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer (CAS 148465-45-6) effective to treat the diarrhea associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day. In yet another embodiment, the present invention provides a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day.

In another embodiment, the present invention provides a method of treating diarrhea associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of crofelemer (CAS 148465-45-6) effective to treat the diarrhea associated with d-IBS. In yet another embodiment, the present invention provides a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of crofelemer effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS. In such embodiments where crofelemer is otherwise formulated (not enterically protected) the dosage of crofelemer administered is bioequivalent to a dosage of about 50 mg per day to about 750 mg per day of orally administered enterically-protected crofelemer. One such exemplary formulation is a controlled-release formulation.

In another embodiment, the present invention provides a method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the diarrhea associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer. In yet another embodiment, the present invention provides a method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer.

Methods of administering an inhibitor of chloride-ion transport include, but are not limited to, parenteral administration (e.g., intradermal, intramuscular, intraperitoneal, intravenous and subcutaneous) and mucosal (e.g., intranasal and oral routes). In a specific embodiment, an inhibitor molecule is administered intramuscularly, intravenously, or subcutaneously. Compositions comprising an inhibitor molecule may be administered by any convenient route, for example, by infusion or bolus injection, by absorption through epithelial or mucocutaneous linings (e.g., oral mucosa, rectal and intestinal mucosa, etc.) and may be administered together with other biologically active agents. Administration can be systemic or local. Preferably, the inhibitor molecule is orally administered.

In certain preferred embodiments of the present invention, the inhibitor molecule is crofelemer (CAS 148465-45-6). In other preferred embodiments, the inhibitor molecule is administered orally. In yet other preferred embodiments, the inhibitor molecule is formulated so as to protect the composition from the stomach environment, i.e., from the acidic environment and digestive proteins found in the stomach. In a preferred embodiment, administration is by oral route and the inhibitor molecule is enteric protected crofelemer.

In certain preferred embodiments, crofelemer is orally administered in an enteric protected form (enteric coated) in a total amount of not more than about 750 mg/day. As used herein, about means within the margin of error. In specific embodiments, the enteric coated crofelemer is orally administered to a subject in an amount of from about 50 mg/day to 750 mg/day. In another embodiment, the enteric coated crofelemer is orally administered to a subject in a total amount of not more than about 500 mg/day. In specific embodiments, the enteric coated crofelemer is orally administered to a subject in an amount of from about 50 mg/day to 500 mg/day. In other embodiments, the enteric coated crofelemer is orally administered to a subject at not more than about 700 mg/day, about 650 mg/day, about 600 mg/day, about 550 mg/day, about 500 mg/day, about 450 mg/day, about 400 mg/day, about 350 mg/day, about 300 mg/day, about 250 mg/day, about 200 mg/day, about 150 mg/day or about 100 mg/day of enteric coated crofelemer. In yet another embodiment, the enteric coated crofelemer is orally administered to a subject in an amount from about 100 mg/day to 750 mg/day. In other embodiments, the enteric coated crofelemer is orally administered to a subject in an amount of from about 125 mg/day to about 500 mg/day, from about 250 mg/day to about 500 mg/day, from about 250 mg/day to about 450 mg/day, from about 250 mg/day to about 400 mg/day, from about 250 mg/day to about 350 mg/day, or from about 250 mg/day to about 300 mg/day. In other particular embodiments, the total dosage of the enteric coated crofelemer orally administered to a subject is about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg, about 90 mg, about 95 mg, about 100 mg, about 105 mg, about 110 mg, about 115 mg, about 120 mg, about 125 mg, about 130 mg, about 135 mg, about 140 mg, about 145 mg, about 150 mg, about 155 mg, about 160 mg, about 165 mg, about 170 mg, about 175 mg, about 180 mg, about 185 mg, about 190 mg, about 195 mg, about 200 mg, about 205 mg, about 210 mg, about 215 mg, about 220 mg, about 225 mg, about 230 mg, about 235 mg, about 240 mg, about 245 mg, about 250 mg, about 255 mg, about 260 mg, about 265 mg, about 270 mg, about 275 mg, about 280 mg, about 285 mg, about 290 mg, about 295 mg, about 300 mg, about 305 mg, about 310 mg, about 315 mg, about 320 mg, about 325 mg, about 330 mg, about 335 mg, about 340 mg, about 345 mg, about 350 mg, about 355 mg, about 360 mg, about 365 mg, about 370 mg, about 375 mg, about 380 mg, about 385 mg, about 390 mg, about 395 mg, about 400 mg, about 405 mg, about 410 mg, about 415 mg, about 420 mg, about 425 mg, about 430 mg, about 435 mg, about 440 mg, about 445 mg, about 450 mg, about 455 mg, about 460 mg, about 465 mg, about 470 mg, about 475 mg, about 480 mg, about 485 mg, about 490 mg, about 495 mg, or about 500 mg once, twice, or three-times per day.

In other embodiments of the invention, the inhibitor molecule, whether a proanthocyanidin polymer composition or an inhibitor of CFTR function, is preferably given at a dosage that is bioequivalent to orally administered enteric coated crofelemer at a dosage of about 50 mg per day to about 750 mg/day or any of the doses listed above. In one embodiment, bioequivalency is a sufficient dose of an inhibitor molecule to produce similar therapeutic effects as seen with another inhibitor molecule at a particular dosage, e.g., crofelemer at a dosage of about 50 mg per day to about 750 mg per day. In another embodiment, bioequivalency is as defined by, or is as determined in accordance with methods approved by, the U.S. Food and Drug Administration.

In a preferred embodiment, crofelemer is enteric coated so as to protect it from degradation by the acidic conditions of the stomach and/or from interactions with proteins, such as pepsin, present in the stomach, i.e., an enteric protected formulation. In a specific embodiment, crofelemer is in tablet form. In yet another specific embodiment, the tablet is enteric coated, e.g., EUDRAGIT®. In a preferred embodiment, crofelemer is formulated as an enteric coated bead or granule in an enteric coated capsule shell. In another embodiment, crofelemer is formulated in a delayed release composition, e.g., Merck GEM, Alza OROS, wax matrix (release is delayed primarily until the formulation passes out of the stomach and into the intestine).

In certain embodiments, the inhibitor molecule is formulated with a compound or compounds which neutralize stomach acid. Alternatively, the pharmaceutical composition containing the inhibitor molecule is administered either concurrent with or subsequent to or after administration of a pharmaceutical composition which neutralize stomach acid. Compounds, such as antacids, which are useful for neutralizing stomach acid include, but are not limited to, aluminum carbonate, aluminum hydroxide, bismuth subnitrate, bismuth subsalicylate, calcium carbonate, dihydroxyaluminum sodium carbonate, magaldrate, magnesium carbonate, magnesium hydroxide, magnesium oxide, and mixtures thereof. Compounds that are able to reduce the secretion of stomach acid and/or are able to reduce the acidity of stomach fluid are well known in the art and include, but are not limited to, antacids (aluminum hydroxide, aluminum carbonate, aluminum glycinate, magnesium oxide, magnesium hydroxide, magnesium carbonate, calcium carbonate, sodium bicarbonate), stomach acid blockers (cimetidine (Tagamet™), famotidine (Mylanta™, Pepcid™), nizatidine (Axid™), ranitidine (Zantac™), omeprazole (Zegerid™)) and a combination of any of the foregoing. In general, any drug that has been approved for sale by the relevant government agency and is able to reduce the production of stomach acid and/or reduce the acidity of stomach fluid can be administered in combination with an inhibitor molecule, such as crofelemer, in accordance with the methods of the invention.

In other embodiments, the inhibitor molecule is administered with other compounds which are useful in treating diarrhea or pain. Such compounds include, but are not limited to, COX-2 inhibitors such as 5-ASA, sulfasalazine, mesalamine, APAZA, as well as other commercially available COX-2 inhibitors such as celecoxib and rofecoxib. Preferably, such compounds are not systemically absorbed or are modified so as to not be systemically absorbed.

In a particular embodiment where crofelemer is not enteric coated, crofelemer is formulated with one or more compounds that are able to reduce the secretion of stomach acid and/or able to reduce the acidity of stomach fluid. Preferably, the dosage of crofelemer to be given in this formulation is a dosage that is bioequivalent to orally administered enteric coated crofelemer at a dosage of about 50 mg per day to about 750 mg per day. In an exemplary embodiment, crofelemer is formulated in a controlled release (delayed release) composition.

In other embodiments, the inhibitor molecules of the invention can be administered in combination with analgesic or anti-inflammatory agents. In a preferred embodiment, the analgesic or anti-inflammatory agent is formulated or modified such that it is not substantially systemically absorbed, i.e., only 20%, 15%, 10%, 5%, 4%, 3%, 2%, 1% or 0.5% absorbed of the dosage given.

The present invention also provides pharmaceutical formulations of chloride-ion transport inhibitors (inhibitor molecules) of the invention comprising an inhibitor molecule along with a pharmaceutically acceptable vehicle, at a dose which is therapeutically effective at treating and/or ameliorating one or more symptoms associated with d-IBS. In one embodiment, a directly compressible proanthocyanidin polymer composition (i.e., that can be directly compressed, without excipients, into a tablet of pharmaceutically acceptable hardness and friability) compressed into a tablet, optionally with a lubricant, such as but not limited to magnesium stearate, is enteric coated. In another embodiment, the pharmaceutical compositions containing the inhibitor molecule of the invention alternatively include one or more substances that either neutralize stomach acid and/or enzymes or are active to prevent secretion of stomach acid. These formulations can be prepared by methods known in the art, see, e.g., methods described in Remington's Pharmaceutical Sciences, 18th Ed., ed. Alfonso R. Gennaro, Mack Publishing Co., Easton, Pa., 1990.

In another preferred embodiment, the pharmaceutical composition comprises a proanthocyanidin polymer composition prepared from a Croton spp, the dosage of which does not exceed 750 mg per day, preferably less than 250 mg/day. In a preferred embodiment, the proanthocyanidin polymer composition of the present invention is crofelemer (CAS 148465-45-6).

The inhibitor molecule can be provided in any therapeutically acceptable pharmaceutical form. The pharmaceutical composition can be formulated for oral administration as, for example but not limited to, drug powders, crystals, granules, small particles (which include particles sized on the order of micrometers, such as microspheres and microcapsules), particles (which include particles sized on the order of millimeters), beads, microbeads, pellets, pills, microtablets, compressed tablets or tablet triturates, molded tablets or tablet triturates, and in capsules, which are either hard or soft and contain the composition as a powder, particle, bead, solution or suspension. The pharmaceutical composition can also be formulated for oral administration as a solution or suspension in an aqueous liquid, as a liquid incorporated into a gel capsule or as any other convenient formulation for administration, or for rectal administration, as a suppository, enema or other convenient form. The inhibitor molecule of the invention can also be provided as a controlled release system (see, e.g., Langer, 1990, Science 249: 1527-1533).

The pharmaceutical formulation can also include any type of pharmaceutically acceptable excipients, additives or vehicles. For example, but not by way of limitation, diluents or fillers, such as dextrates, dicalcium phosphate, calcium sulfate, lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch, sorbitol, sucrose, inositol, powdered sugar, bentonite, microcrystalline cellulose, or hydroxypropylmethylcellulose may be added to the inhibitor molecule to increase the bulk of the composition. Also, binders, such as but not limited to, starch, gelatin, sucrose, glucose, dextrose, molasses, lactose, acacia gum, sodium alginate, extract of Irish moss, panwar gum, ghatti gum, mucilage of isapgol husks, carboxymethylcellulose, methylcellulose, polyvinylpyrrolidone, Veegum and starch arabogalactan, polyethylene glycol, ethylcellulose, and waxes, may be added to the formulation to increase its cohesive qualities. Additionally, lubricants, such as but not limited to, talc, magnesium stearate, calcium stearate, stearic acid, hydrogenated vegetable oils, polyethylene glycol, sodium benzoate, sodium acetate, sodium chloride, leucine, carbowax, sodium lauryl sulfate, and magnesium lauryl sulfate may be added to the formulation. Also, glidants, such as but not limited to, colloidal silicon dioxide or talc may be added to improve the flow characteristics of a powdered formulation. Finally, disintegrants, such as but not limited to, starches, clays, celluloses, algins, gums, crosslinked polymers (e.g., croscarmelose, crospovidone, and sodium starch glycolate), Veegum, methylcellulose, agar, bentonite, cellulose and wood products, natural sponge, cation-exchange resins, alginic acid, guar gum, citrus pulp, carboxymethylcellulose, or sodium lauryl sulfate with starch may also be added to facilitate disintegration of the formulation in the intestine.

In one aspect of this embodiment, crofelemer is formulated for oral administration. In other aspects, the pharmaceutical dosage form is formulated to protect the inhibitor molecule, e.g., crofelemer, from degradation by the acidic conditions of the stomach and from interactions with proteins, such as pepsin, present in the stomach. Thus, in a preferred aspect, the formulation is enteric coated. For example, the enteric coated formulation is enteric coated tablets, beads or granules, which optionally contain a lubricant such as, but not limited to, magnesium stearate. The enteric coated formulations include enteric coated beads in a capsule, enteric coated microspheres in a capsule, enteric coated microspheres provided in a suspension or mixed with food, which suspensions are particularly convenient for pediatric administration, and enteric coated compressed tablets. The capsule can be a hard-shell gelatin capsule or a cellulose capsule. In particular, the pharmaceutical composition is formulated as an enteric coated capsule. In one specific aspect, a proanthocyanidin polymer composition is administered in tablet form, which tablet is backfilled with microcrystalline cellulose.

In one embodiment, the inhibitor molecule is directly compressed, that is, the inhibitor molecule, with or without any excipients, can be compressed into a tablet, or other pharmaceutical formulation, that has a pharmaceutically acceptable hardness and friability. Preferably, the directly compressible pharmaceutical composition can be compressed into tablets having a hardness of greater than 4 kp (kiloponds), preferably a hardness of 8 to 14 kp, more preferably a hardness of 10 to 13 kp. A directly compressible composition can be compressed into a tablet that has a friability of not more than 1% loss in weight, preferably less than 0.8% loss in weight, more preferably less than 0.5% loss in weight.

In a preferred embodiment, the directly compressible formulation consists of 99.93% crofelemer and 0.07% magnesium stearate and is coated with a methacrylic acid copolymer. In another preferred embodiment, the pharmaceutical formulation contains a directly compressible inhibitor molecule but no excipients, additives or vehicles other than an enteric coating; however, the formulation may contain a lubricant, such as but not limited to, magnesium stearate. Preferably, a directly compressed proanthocyanidin polymer composition formulation is formulated as a tablet of pharmaceutically acceptable hardness (greater than 4 kp, preferably 8-14 kp, and more preferably 10-13 kp) and friability (not more than 1% loss in weight, preferably less than 0.8% loss in weight, and more preferably less than 0.5% loss in weight).

In a more preferred embodiment, the inhibitor molecule is enteric coated. Enteric coatings are those coatings that remain intact in the stomach, but will dissolve and release the contents of the dosage form once it reaches the small intestine. A large number of enteric coatings are prepared with ingredients that have acidic groups such that, at the very low pH present in the stomach, i.e. pH 1.5 to 2.5, the acidic groups are not ionized and the coating remains in an undissociated, insoluble form. At higher pH levels, such as in the environment of the intestine, the enteric coating is converted to an ionized form, which can be dissolved to release the inhibitor molecule. Other enteric coatings remain intact until they are degraded by enzymes in the small intestine, and others break apart after a defined exposure to moisture, such that the coatings remain intact until after passage into the small intestines.

Polymers which are useful for the preparation of enteric coatings include, but are not limited to, shellac, starch and amylose acetate phthalates, styrene-maleic acid copolymers, cellulose acetate succinate, cellulose acetate phthalate (CAP), polyvinylacetate phthalate (PVAP), hydroxypropylmethylcellulose phthalate (grades HP-50 and HP-55), ethylcellulose, fats, butyl stearate, and methacrylic acid-methacrylic acid ester copolymers with acid ionizable groups (including “ACRYLEZE®” and “EUDRAGIT®”), such as “EUDRAGIT® L 30D”, “EUDRAGIT® RL 30D”, “EUDRAGIT® RS 30D”, “EUDRAGIT® L 100-55”, and “EUDRAGIT® L 30D-55”. In a preferred embodiment, the pharmaceutical composition contains an inhibitor of chloride-ion transport, such as a proanthocyanidin polymeric composition, and the enteric coating polymer “EUDRAGIT® L 30D”, an anionic copolymer of methacrylic acid and methyl acrylate with a mean molecular weight of 250,000 Daltons. In another preferred embodiment, the enteric coating polymer is “EUDRAGIT® L 30D-55”.

The disintegration of the enteric coating occurs either by hydrolysis by intestinal enzymes or by emulsification and dispersion by bile salts, depending upon the type of coating used. For example, esterases hydrolyze esterbutyl stearate to butanol and stearic acid and, as the butanol dissolves, the stearic acid flakes off of the medicament. Additionally, bile salts emulsify and disperse ethylcellulose, hydroxypropylmethylcellulose, fats and fatty derivatives. Other types of coatings are removed depending on the time of contact with moisture, for example coatings prepared from powdered camauba wax, stearic acid, and vegetable fibers of agar and elm bark rupture after the vegetable fibers absorb moisture and swell. The time required for disintegration depends upon the thickness of the coating and the ratio of vegetable fibers to wax.

Application of the enteric coating to the inhibitor molecule of the invention can be accomplished by any method known in the art for applying enteric coatings. For example, but not by way of limitation, the enteric polymers can be applied using organic solvent based solutions containing from 5 to 10% w/w polymer for spray applications and up to 30% w/w polymer for pan coatings. Solvents that are commonly in use include, but are not limited to, acetone, acetone/ethyl acetate mixtures, methylene chloride/methanol mixtures, and tertiary mixtures containing these solvents. Some enteric polymers, such as methacrylic acid-methacrylic acid ester copolymers can be applied using water as a dispersant. The volatility of the solvent system must be tailored to prevent sticking due to tackiness and to prevent high porosity of the coating due to premature spray drying or precipitation of the polymer as the solvent evaporates.

Furthermore, plasticizers can be added to the enteric coating to prevent cracking of the coating film. Suitable plasticizers include the low molecular weight phthalate esters, such as diethyl phthalate, acetylated monoglycerides, triethyl citrate, polyethyl glycoltributyl citrate and triacetin. Generally, plasticizers are added at a concentration of 10% by weight of enteric coating polymer weight. Other additives such as emulsifiers, for example detergents and simethicone, and powders, for example talc, may be added to the coating to improve the strength and smoothness of the coating. Additionally, pigments may be added to the coating to add color to the pharmaceutical formulation.

In preferred embodiments, a pharmaceutical composition of the inhibitor molecule is provided as enteric coated beads in hard-shell gelatin capsules. In a preferred embodiment, proanthocyanidin polymer beads are prepared by mixing a proanthocyanidin polymer composition with hydroxypropylmethylcellulose and layering the mixture onto nonpareil seeds (sugar spheres). In a more preferred embodiment, crofelemer, which is directly compressible, without any excipients, additives or vehicles other than an enteric coating, is milled and fractionated into beads (i.e., as beads that do not contain the nonpareil sugar seeds). The beads may be covered with a seal coat of Opadry Clear (mixed with water). A preferred enteric coating of the beads is “EUDRAGIT™ L 30D” or “EUDRAGIT™ L 30D-55” applied as an aqueous dispersion containing 20%-30% w/w dry polymer substance, which is supplied with 0.7% sodium lauryl sulfate NF (SLS) and 2.3% polysorbate 80 NF (Tween™ 20) as emulsifiers, to which plasticizers, such as polyethylene glycol and/or citric acid esters, are added to improve the elasticity of the coating, and talc can be added to reduce the tendency of the enteric coating polymer to agglutinate during the application process and to increase the smoothness of the film coating.

In a preferred formulation, the final composition of enteric coated proanthocyanidin polymer composition beads containing the nonpareil seeds is 17.3% w/w nonpareil seeds, 64.5% w/w proanthocyanidin polymer composition, 1.5% w/w hydroxypropylmethylcellulose, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D”, 1.45% w/w triethyl citrate, and 0.25% w/w glyceryl monostearate. This pharmaceutical formulation may be prepared by any method known in the art or by the method described in Example 1, infra.

A preferred formulation of the proanthocyanidin polymer composition beads not containing the nonpareil seeds is 78% w/w directly compressible proanthocyanidin polymer composition (e.g., isolated by the method described in the Examples), 0.76% w/w Opadry Clear, 19% w/w “EUDRAGITTM L 30D-55”, 1.9% triethyl citrate, and 0.34% w/w glyceryl monostearate. This pharmaceutical formulation may be prepared by any method known in the art or by the method described in Example 2, infra.

Another preferred formulation contains 54.58% w/w proanthocyanidin polymer composition beads (without non-pareil seeds and made of a directly compressible proanthocyanidin polymer composition), 1.78% w/w Opadry Clear, 39% w/w “EUDRAGITTM L 30D-55”, 3.9% triethylcitrate, and 0.74% w/w glyceryl monostearate.

In another embodiment, the pharmaceutical composition comprising the inhibitor molecule of the invention is formulated as enteric coated granules or powder (microspheres with a diameter of 300-500 μ) provided in either hard shell gelatin capsules or suspended in an oral solution for pediatric administration. The enteric coated powder or granules may also be mixed with food, particularly for pediatric administration. This preparation may be prepared using techniques well known in the art, such as the method described in Example 1C, infra.

In general, the granules and powder can be prepared using any method known in the art, such as but not limited to, crystallization, spray-drying or any method of comminution, preferably using a high speed mixer/granulator. Examples of high speed mixer/granulators include the “LITTLEFORD LODIGE™” mixer, the “LITTLEFORD LODIGE™” MGT mixer/granulator, and the “GRAL™” mixer/granulator. During the high-shear powder mixing, solutions of granulating agents, called binders, are sprayed onto the powder to cause the powder particles to agglomerate, thus forming larger particles or granules. Granulating agents which are useful for preparing the granules, include but are not limited to, cellulose derivatives (including carboxymethylcellulose, methylcellulose, and ethylcellulose), gelatin, glucose, polyvinylpyrrolidone (PVP), starch paste, sorbitol, sucrose, dextrose, molasses, lactose, acacia gum, sodium alginate, extract of Irish moss, panwar gum, ghatti gum, mucilage of isapol husks, Veegum and larch arabogalactan, polyethylene glycol, and waxes. Granulating agents may be added in concentrations ranging from 1 to 30% of the mass of the particles or granules.

The powder or granules are preferably coated using the fluidized bed equipment. The granules or powder may then be covered with a seal coat of Opadry Clear (mixed with water). A preferred enteric coating is “EUDRAGIT™ L 30D” applied as an aqueous dispersion containing 30% w/w dry polymer substance, which is supplied with 0.7% sodium lauryl sulfate NF (SLS) and 2.3% polysorbate 80 NF (Tween™ 20) as emulsifiers, to which the plasticizers, polyethylene glycol and citric acid esters, are added to improve the elasticity of the coating, and talc is added to reduce the tendency of the enteric coating polymer to agglutinate during the application process and to increase the smoothness of the film coating. In a preferred embodiment, the final composition of an enteric coated powder is 81.8% w/w proanthocyanidin polymer composition, 1.5% w/w hydroxypropylmethylcellulose, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D”, 1.45% w/w triethyl citrate, and 0.25% w/w glyceryl monostearate. The final composition of the enteric coated granules is 81.8% w/w proanthocyanidin polymer composition, 10% polyvinylpyrrolidone, 1.5% w/w hydroxypropylmethylcellulose, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D”, 1.45% w/w triethyl citrate, and 0.25% w/w glyceryl monostearate.

The enteric coated granules or powder particles can further be suspended in a solution for oral administration, particularly for pediatric administration. The suspension can be prepared from aqueous solutions to which thickeners and protective colloids are added to increase the viscosity of the solution to prevent rapid sedimentation of the coated powder particles or granules. Any material which increases the strength of the hydration layer formed around suspended particles through molecular interactions and which is pharmaceutically compatible with the inhibitor molecule can be used as a thickener, such as but not limited to, gelatin, natural gums (e.g., tragacanth, xanthan, guar, acacia, panwar, ghatti, etc.), and cellulose derivatives (e.g., sodium carboxymethylcellulose, hydroxypropylcellulose, and hydroxypropylmethylcellulose, etc.). Optionally, a surfactant such as Tween™ may be added to improve the action of the thickening agent. A preferred suspension solution is a 2% w/w hydroxypropylmethylcellulose solution in water containing 0.2% Tween™.

The inhibitor molecule can also be formulated as enteric coated tablets. In one preferred embodiment, a proanthocyanidin polymer composition is granulated with any pharmaceutically acceptable diluent (such as those listed above) by the methods described above for preparing the granules. Then, the granules are compressed into tablets using any method well known in the art, for example but not limited to, the wet granulation method, the dry granulation method or the direct compression method. Preferred diluents include, but are not limited to, microcrystalline cellulose (“AVICEL™ PH 200/300”) and dextrates (“EMDEX™”). Additionally, disintegrants, such as those described above, and lubricants, such those described above, may also be added to the tablet formulation. A preferred tablet formulation contains 250 mg proanthocyanidin polymer composition, 7 mg of the disintegrant “AC-DI-SOL™” (cross linked sodium carboxymethylcellulose), 1.75 mg of the lubricant magnesium stearate and the weight of “AVICEL™ PH 200/300” necessary to bring the mixture up to 350 mg. The tablets are coated with an enteric coating mixture prepared from 250 grams “EUDRAGIT™ L 30 D-55”, 7.5 grams triethyl citrate, 37.5 grams talc and 205 grams water. This formulation may be prepared by any method well known in the art.

In a preferred embodiment, a directly compressible proanthocyanidin polymer composition is made into granules by size reduction (e.g., as described above) and mixed with a lubricant, preferably, magnesium stearate. Then, the lubricated granules are compressed into tablets using any method well-known in the art, for example but not limited to, the direct compression method. Preferably, each tablet is 125 mg containing 99.6% w/w directly compressible proanthocyanidin polymer composition and 0.40% w/w magnesium stearate. The tablets are then preferably coated with an enteric coating mixture of a 30% suspension (6.66 g in 22.22 g) of “EUDRAGIT™ L 30D-55 ”, 0.67 g triethyl citrate, 1.67 g talc and 20.44 g purified water, per 100 grams of tablet. The tablets can be prepared by any method known in the art or by the method described in Example 1E, infra.

In a more preferred embodiment, a directly compressible proanthocyanidin polymer composition is formulated into core tablets of either 125 mg, 250 mg or 500 mg containing 99.6% w/w directly compressible proanthocyanidin polymer composition and 0.40% w/w magnesium stearate. The tablets are then preferably coated with an enteric coating mixture. The final composition of the tablets is 86.6% w/w directly compressible proanthocyanidin polymer composition, 0.4% magnesium stearate, 6.5% “EUDRAGIT™ L30D-55”, 0.9% triethyl citrate, 2.87% talc, and 2.74% white dispersion. The tablets can be prepared by any method known in the art, for example but not limited to the method described infra.

The compositions formed into small particles (which include particles sized on the order of micrometers, such as microspheres and microcapsules), particles (which include particles sized on the order of millimeters), drug crystals, pellets, pills and microbeads can be coated using a fluidized-bed process. This process uses fluidized-bed equipment, such as that supplied by “GLATT™”, “AEROMATIC™”, “WURSTER™”, or others, by which the composition cores are whirled up in a closed cylindrical vessel by a stream of air, introduced from below, and the enteric coat is formed by spray drying it onto the cores during the fluidization time. To coat tablets or capsules, Accela-Cota coating equipment (“MANESTY™”) can be used. By this process, the tablets or capsules are placed in a rotating cylindrical coating pan with a perforated jacket and spraying units are installed within the pan and the dry air is drawn in through the rotating tablets or capsules. Any other type of coating pan, such as the “COMPU-LAB™” pan, Hi-coates “GLATT™”immersion sword process, the “DRIAM™” Dricoater, “STEINBERG™” equipment, “PELLEGRINI™” equipment, or “WALTHER™” equipment can also be used.

The pharmaceutical formulations of the invention can also be used to treat d-IBS in non-human animals, particularly in farm animals, such as but not limited to, bovine animals, swine, ovine animals, poultry (such as chickens), and equine animals, and other domesticated animals such as canine animals and feline animals. In particular, the pharmaceutical formulations of the invention can be used to treat d-IBS disease in non-human animals, particularly food animals such as cattle, sheep and swine by incorporating the pharmaceutical compositions of the invention into the animal's feed.

According to the methods of the present invention, the pharmaceutical compositions of comprising chloride-ion transport inhibitors (inhibitor molecules) of the invention are administered to a subject in a total amount that is bioequivalent to not more than 750 mg/day of orally administered enteric protected crofelemer. In specific embodiments, pharmaceutical compositions comprising crofelemer are administered to a subject in an amount of between about 50 mg per day and about 250 mg/day.

In determining whether a subject has diarrhea-predominant IBS, any method can be used in the art to diagnose the subject including, but not limited to, the Rome II criteria for diagnosis of irritable bowel syndrome (Thompson et al., 1999, Gut 45 (Suppl II):II-43-1147). Briefly, the Rome II diagnostic criteria state that for at least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has two of three features: (1) relief with defecation, and/or (2) onset associated with a change in frequency of stool; and/or (3) onset associated with a change in form (appearance) of stool. The following symptoms cumulatively support the diagnosis of d-IBS: (i) abnormal stool frequency, e.g., greater than 3 times per day; (ii) abnormal stool form, e.g., loose/watery stool; (iii) presence of urgency (having to rush to have a bowel movement).

Definitions

Unless otherwise defined, all terms of art, notations and other scientific terms or terminology used herein are intended to have the meanings commonly understood by those of skill in the art to which this invention pertains. In some cases, terms with commonly understood meanings are defined herein for clarity and/or for ready reference, and the inclusion of such definitions herein should not necessarily be construed to represent a substantial difference over what is generally understood in the art. The practice of the present invention will employ, unless otherwise indicated, conventional techniques of molecular biology (including recombinant techniques), microbiology, cell biology, biochemistry, nucleic acid chemistry, and immunology, which are within the skill of the art. Such techniques are explained fully in the literature, such as, Current Protocols in Immunology (J. E. Coligan et al., eds., 1999, including supplements through 2001); Current Protocols in Molecular Biology (F. M. Ausubel et al., eds., 1987, including supplements through 2001); Molecular Cloning: A Laboratory Manual, third edition (Sambrook and Russel, 2001); PCR: The Polymerase Chain Reaction, (Mullis et al., eds., 1994); The Immunoassay Handbook (D. Wild, ed., Stockton Press NY, 1994); Bioconjugate Techniques (Greg T. Hermanson, ed., Academic Press, 1996); Methods of Immunological Analysis (R. Masseyeff, W. H. Albert, and N. A. Staines, eds., Weinheim: VCH Verlags gesellschaft mbH, 1993), Harlow and Lane Using Antibodies: A Laboratory Manual Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y., 1999; and Beaucage et al. eds., Current Protocols in Nucleic Acid Chemistry John Wiley & Sons, Inc., New York, 2000).

As used herein, the term “derivative” in the context of polypeptides or proteins refers to a polypeptide or protein that comprises an amino acid sequence which has been altered by the introduction of amino acid residue substitutions, deletions or additions. The term “derivative” as used herein also refers to a polypeptide or protein which has been modified, i.e., by the covalent attachment of any type of molecule to the polypeptide or protein. For example, but not by way of limitation, an antibody may be modified, e.g., by glycosylation, acetylation, pegylation, phosphorylation, amidation, derivatization by known protecting/blocking groups, proteolytic cleavage, linkage to a cellular ligand or other protein, etc. A derivative polypeptide or protein may be produced by chemical modifications using techniques known to those of skill in the art, including, but not limited to specific chemical cleavage, acetylation, formylation, metabolic synthesis of tunicamycin, etc. Further, a derivative polypeptide or protein derivative possesses at least one similar or identical biological function as the polypeptide or protein from which it was derived.

As used herein, the term “derivative” in the context of a non-proteinaceous derivative refers to a second organic or inorganic molecule that is formed based upon the structure of a first organic or inorganic molecule. A derivative of an organic molecule includes, but is not limited to, a molecule modified, e.g., by the addition or deletion of a hydroxyl, methyl, ethyl, carboxyl, amine group, esterification, alkylation or phosphorylation, immobilization or addition of a polymer.

As used herein, the term “polymer” refers to compounds comprising three or more monomeric units which may be the same or different. Thus, “polymer” refers to high molecular weight and/or insoluble polymers as well as low molecular weight and/or soluble oligomers.

As used herein, the term “fragment” refers to a peptide or polypeptide comprising an amino acid sequence of at least 5 contiguous amino acid residues. In one embodiment, a fragment of a polypeptide retains at least one function of the polypeptide.

As used herein, the term “inhibiting CFTR function” refers to inhibiting any function of a CFTR molecule by any means including, but not limited to, inhibiting chloride ion transport, and inhibiting expression of the CFTR molecule.

As used herein, the terms “nucleic acids” and “nucleotide sequences” include DNA molecules (e.g., cDNA or genomic DNA), RNA molecules (e.g., mRNA), combinations of DNA and RNA molecules or hybrid DNA/RNA molecules, and analogs of DNA or RNA molecules.

As used herein, the terms “subject” and “patient” are used interchangeably. As used herein, the terms “subject” and “subjects” refer to an animal, preferably a mammal including a non-primate (e.g., a cow, pig, horse, cat, dog, rat, and mouse) and a primate (e.g., a monkey, such as a cynomolgous monkey, and a human), and more preferably a human. In a preferred embodiment, the subject is a human. In a one embodiment, the term “subject” excludes those subjects who suffer from or have been diagnosed with secretory (acute) diarrhea.

As used herein, the terms “treat”, “treatment” and “treating” refer to the prevention, reduction, amelioration or elimination of a symptom or complication of d-IBS. The term “prevention, reduction, amelioration or elimination of a symptom of d-IBS” in the context of the present invention refers to at least one of the following: prevention of d-IBS before it occurs, for example, in patients that suffered in the past from d-IBS but are now in a period of remission; elimination of established d-IBS (as determined by, for example, the return of normal stool frequency); elimination of pain associated with d-IBS; reduction of an undesired symptom of the disease as manifested by a decrease in the severity of an existing condition of d-IBS; elimination or reduction of one or more medications used in treating the subject. The reduction in the undesired symptom may be determined by, for example, measuring stool frequency, determining stool consistency, determining the presence of urgency, determining pain associated with d-IBS as compared to before treatment. Any amount of reduction in the severity of a symptom, even if some of the symptom remains at a lower, more acceptable level (“management”), is encompassed by the term herein defined. Such remediation may be evident as a reduction in stool frequency, increase in stool consistency, lessening of the presence of urgency, lessening of pain.

Since d-IBS is always accompanied by other non diarrhea-related symptoms, such as abdominal discomfort, pain, bloating, fatigue, sleep disturbances, sexual dysfunction, headache, fibromyalgia (muscle aching), dyspepsia (upper abdominal discomfort or pain), chest pain, urinary or gynecological symptoms, anxiety and depression. Reduction in at least one of these symptoms is also encompassed by the term “prevention reduction, management or elimination of a symptom or complication of d-IBS.”

As used herein, the term “therapeutically effective amount” refers to that amount of the therapeutic agent sufficient to result in the treatment of d-IBS, to prevent advancement of d-IBS, cause regression of d-IBS, or to enhance or improve the therapeutic effect(s) of another therapeutic agent administered to treat or prevent d-IB S.

The following series of Examples are presented for purposes of illustration and not by way of limitation on the scope of the invention.

EXAMPLES Example 1 Preparation of Pharmaceutical Formulations

Described below are illustrative methods for the manufacture and packaging for different preferred pharmaceutical formulations of the proanthocyanidin polymer composition from C. lechleri according to the present invention.

1A. Encapsulated Enteric Coated Beads

Detailed descriptions of the batch formula and methods used to prepare the encapsulated enteric coated proanthocyanidin polymer composition bead formulation based on sugar spheres are provided below. Each hard-shell gelatin capsule contained 250 mg proanthocyanidin polymer composition enteric coated beads. Capsules were packaged in HDPE bottles containing sixteen (16) 250 mg caps each. The formulation for enteric coated proanthocyanidin polymer composition beads contained 17.3% (w/w) of nonpareil seeds (sugar spheres 40/60 mesh, Paulaur, lot #60084060), 64.5% proanthocyanidin polymer composition from C. lechleri, 1.5% hydroxypropylmethylcellulose (Methocel E5 Premium, Dow Chemical Co., lot #MM9410162E), 0.5% Opadry Clear (Colorcon, lot #S83563), 14.5% “EUDRAGIT™ L 30D” (Rohm Tech., lot #1250514132), 1.45% triethyl citrate (Morflex, lot #N5X291), glyceryl monostearate (Imwitor-900, Rohm Tech, lot #502-229), and purified water (USP).

The layering coating solution containing the proanthocyanidin polymer composition was prepared by adding hydroxypropylmethylcellulose and the proanthocyanidin polymer composition to purified water (USP) and mixing until dissolved. The nonpareil seeds were loaded into the product bowl of the fluid bed processor (Nior-Precision Coater). The polymer solution was then layered on the nonpareil seeds by spraying the solution onto the fluidized nonpareil seeds at a target bed temperature of 30-35° C. Once the proanthocyanidin polymer layering had been completed, a seal coat using Opadry Clear (preparing by mixing the Opadry Clear with Purified Water, USP) was applied with a target bed temperature of 30-35° C. After the seal coat was applied, the pellets were discharged and screened through 1000 μ and 425 μ screens, and the layered spheres larger than 425 μ and smaller than 1000 μ were charged back into the fluid bed processor. Meanwhile, the enteric coating solution was prepared by mixing triethyl citrate and glyceryl monostearate to water that had been heated to 65° C. and then mixing this solution with the “EUDRAGIT™ L 30D-55”. The resulting enteric coating solution was then sprayed onto the layered spheres in the fluidized bed processor, at a bed temperature of 30-35° C., until all the enteric coating solution was layered on the beads. Based on the results of the HPLC assay indicating that the proanthocyanidin polymer composition was present at a concentration of 52.9%, the enteric coated beads were hand filled into a Size #0 hard shell gelatin capsule to provide a 250 mg dosage and then packaged into a suitable HDPE bottles with a heat induction lined cap.

TABLE 1 BATCH FORMULA Product: Proanthocyanidin Polymer Enteric Coated Beads Batch Size: 578.0 gm Raw Material Amount Used Per Batch Sugar Nonpareil Spheres, NF (40/60) 100.0 gm Proanthocyanidin Polymer Composition 372.8 gm Hydroxypropylmethylcellulose E5, USP  8.7 gm (K29/32) Opadry Clear (YS-1-19025A)  2.9 gm “EUDRAGIT ™ L 30D-55” 279.4 gm (30% solids) Triethyl Citrate, NF  8.4 gm Glycerol Monostearate  1.4 gm Water, USP (Removed during processing) 1284.8 gm 

1B. Encapsulated Enteric Coated Beads

Described below are the formula and methods used to prepare encapsulated enteric coated bead formulations that do not contain nonpareil sugar spheres. One formulation contains 83.3% w/w proanthocyanidin polymer composition, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D-55”, 1.9% w/w triethyl citrate and a 0.34% glyceryl monostearate.

The beads were first seal coated with a 5% solution of Opadry clear in a 16 liter aeromatic MP-1 fluidized bed processor with a 50 mm Wurster column. The coating parameters for the application of the seal coating were an inlet temperature of 50° C. to 60° C., an outlet temperature of 25° C. to 40° C., an air volume of 30 to 40 CMH, a spray rate of 6 to 12 grams per minute, and an air pressure of 2.5 Bar. After the seal coat was applied, the beads were discharged and screened for beads larger than 425 μ and smaller than 1000 μ. The beads of appropriate size were then charged back into the fluid bed processes for enteric coating. For each 1000 grams of proanthocyanidin polymer composition beads, an enteric coating suspension was prepared from 811.97 grams “EUDRAGIT™ L 30D-55”, 24.36 grams triethyl citrate, 4.36 grams glyceryl monostearate and 248.55 grams purified water. This suspension was prepared by gently stirring the “EUDRAGIT™ L 30D-55” suspension continually and, in a separate container, suspending and homogenizing the triethyl citrate and talc in purified water. The triethyl citrate/talc mixture was then added to the “EUDRAGIT™ L 30D-55” suspension, and the resulting coating dispersion stirred during the spraying process to avoid settling. The beads were then coated in the fluidized bed processor under the following parameters: The inlet temperature was 42° C. to 47° C.; the outlet temperature was 28° C. to 34° C.; the air volume was 30-40 CMH; the spray rate was 6-12 grams/minute; and the air pressure was 2.5 Bars. The resulting enteric coated beads were then filled into a size #0 hard shell gelatin capsule.

1C. Enteric Coated Granules and Powder Particles

Described below is a method for formulating the proanthocyanidin polymer composition as enteric coated granules or powder (microspheres with a diameter of 300-500μ) in either hard shell gelatin capsules or suspended in an oral solution. The proanthocyanidin polymer composition powder particles are prepared by high-shear powder mixing of the proanthocyanidin polymer composition and hydroxypropylmethylcellulose in a high speed mixer/granulator. The proanthocyanidin polymer composition granules are prepared by spraying polyvinylpyrrolidone on the powder in the high speed mixer/granulator so that the powder particles agglomerate to form larger granules. Using fluidized bed equipment, the granules or powder are then covered with a seal coat of Opadry Clear (mixed with water) and then coated with the enteric coating “EUDRAGIT™ L 30D” applied as an aqueous dispersion containing 30% w/w dry methacrylate polymer substance, which is supplied with 0.7% sodium lauryl sulfate NF (SLS) and 2.3% polysorbate 80 NF (Tween™ 20) as emulsifiers, to which the plasticizers, triethyl citrate and glyceryl monostearate, are added to improve the elasticity of the coating. The final composition of the enteric coated powder is 81.8% w/w proanthocyanidin polymer composition, 1.5% w/w hydroxypropylmethylcellulose, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D”, 1.45% w/w triethyl citrate, and 0.25% w/w glyceryl monostearate. The final composition of the enteric coated granules is 81.8% w/w proanthocyanidin polymer composition, 10% polyvinylpyrrolidone, 1.5% w/w hydroxypropylmethylcellulose, 0.5% w/w Opadry clear, 14.5% w/w “EUDRAGIT™ L 30D”, 1.45% w/w triethyl citrate, and 0.25% w/w glyceryl monostearate.

The enteric coated proanthocyanidin polymer composition granules or particles may be filled into a hard shell gelatin capsule in an amount which provides a suitable dosage.

The enteric coated proanthocyanidin polymer composition granules or powder particles can also be suspended in a solution for oral administration, particularly for pediatric administration. The suspension solution is prepared by wetting 2 grams hydroxypropylmethylcellulose in 97.8 ml distilled water and 0.2 grams Tween™ 80; mixing this preparation to homogeneity by sonicating, heating the solution to 40° C. and stirring for three hours; and then adding the enteric coated proanthocyanidin polymer composition powder particles or granules to the homogeneous solution.

1D. Enteric Coated Compressed Tablets

A method for formulating the proanthocyanidin polymer composition with a diluent as enteric coated tablets is described below. For each 350 mg tablet, 250 mg proanthocyanidin polymer composition is granulated with 7 mg crosslinked sodium carboxymethylcellulose (“AC-DI-SOL™”) and a sufficient mass of microcrystalline cellulose (“AVICEL™ PH 200/300”) to bring the total mass to 350 mg. These ingredients are mixed for 20 to 30 minutes in a V blender. After the 20 to 30 minutes of mixing, 1.75 mg magnesium stearate is added and the mixture is blended for an additional 4 to 5 minutes. The resulting granules are compressed on a rotary tablet press using 5/16th inch standard concave punches. The tablets are coated with an enteric coating mixture prepared from 250 grams “EUDRAGIT™ L 30 D-55”, 7.5 grams triethyl citrate, 37.5 grams talc and 205 grams water. The tablets are then placed in a perforated pan coater (e.g. the “ACCELA-COTA™” system) and rotated at 15 rpm at 40° C. The enteric coating formulation is sprayed using the following conditions: inlet air temperature of 44° C.-48° C., exhaust air temperature of 29° C.-32° C., product temperature of 26° C.-30° C., a 1 mm spray nozzle, a pan speed of 30 to 32 rpm, an airflow of 30-32 CFM, and a spray pressure of 20 PSI. The tablets are finally cured for 30 minutes as the pan is rotating at 15 rpm with an inlet air temperature of 60° C. and then, after shutting off the heat, the tablets are rotated at 15 rpm until the tablets have cooled to room temperature.

1E. Enteric Coated Directly Compressed Tablets

A method for formulating the proanthocyanidin polymer composition without a diluent as enteric coated tablets was carried out as described below. Directly compressible proanthocyanidin polymer composition was produced according to the method described in Example 1F, infra. 125 mg tablets were prepared by blending 99.6% w/w directly compressible proanthocyanidin polymer composition with 0.40% w/w magnesium stearate for two minutes and then directly compressing the material into 125 mg tablets on a rotary press using ¼ inch diameter round standard concave punches to a tablet hardness of 4-10 Kp.

The core tablets were tested and found to have an average hardness (n=10) of 4-10 Kp, friability (n=20) of less than 0.7%, an average table weight (n=10) of 125 mg±7 mg, an average thickness (n=10) of 3.9 to 4.1 mm, and a disintegration time (n=6) of not more than 20 minutes.

The coating dispersion was prepared by mixing, per 100 grams of tablets, 22.22 grams of a 30% w/w “EUDRAGIT™ L 30D-55” suspension, kept gently stirred with a mixture of 0.67 grams triethyl citrate, 1.67 grams talc and 20.44 grams purified water which had been mixed until homogeneous. The coating dispersion was continually stirred to avoid settling.

The tablets (in batches of 100,000) were coated with the coating dispersion in a Compu-Lab 24 inch/30 L pan. The tablets were jogged in the pan at a speed of 3-5 rpm and pre-warmed to a temperature of 35° C. to 40° C. The tablets were then coated with the enteric coating dispersion to a 6% to 8% weight gain with the following parameters: an inlet temperature of 45° C. to 65° C.; an exhaust air temperature of 27° C. to 34° C.; a product temperature of 28° C. to 32° C.; a pan speed of 8-14 rpm; an air flow of 180 to 240 CHM; an air spray pressure of 10-20 psi (pounds per square inch); an initial spray rate of 3 to 4 grams/min/kg; and a final spray rate of 4 to 8 grams/min/kg. The tablets were then cured for 30 minutes in the pan with an inlet temperature of 45° C. to 50° C. and a pan speed of 3 to 5 rpm. Finally, the tablets were allowed to cool to room temperature in the pan at a pan speed of 3 to 5 rpm. Four of the 125 mg tablets were then filled into a size zero, opaque Swedish orange-colored gelatin capsule.

The enteric coated proanthocyanidin polymer composition tablets were tested for content uniformity, drug release, microbiological tests and stability, and some analytical in process tests were also performed. In stability studies, the proanthocyanidin polymer composition remained stable after six months of storage at room temperature as well as under accelerated temperature and humidity conditions. Finally, the core tablets were tested and found to have an average hardness (n=10) of 4-10 Kp, friability (n=20) of less than 0.7%, an average tablet weight (n=10) of 125 mg±7 mg, an average thickness (n=10) of 3.9 to 4.1 mm, and a disintegration time (n=6) of not more than 20 minutes.

1F. Enteric Coated Directly Compressed Tablets

Formulation of the proanthocyanidin polymer composition, without a diluent, as enteric coated tablets was carried out as described below. The directly compressible proanthocyanidin polymer composition was isolated as described in Example 2, infra. The core tablets were prepared by milling 250 mg proanthocyanidin polymer composition per tablet (approximately 16 kg total) in a Quadro Comil with an 024R (30 mesh) screen and then blending the milled composition in a Patterson Kelley 2 cubic foot twin shell blender. 1 mg magnesium stearate (Spectrum Quality Products, Inc., New Brunswick, N.J.) per tablet was then added to the composition in the blender and blended for 2 minutes. The blend was then compressed into 251 mg tablets (containing 250 mg proanthocyanidin polymer composition) on a rotary tablet press to a tablet hardness of 8-15 Kp and friability less than 0.5%.

The coating dispersion was prepared by first mixing in a first container the 25 g (7.5 g solids) “EUDRAGIT™ L 30 D-55” (Huls America, Inc., Somerset, N.J.) (weight given per 115 grams coated tablets) dispersion. The pigment dispersion was prepared by adding sequentially with constant stirring in a second container 39.59 g purified water, 3.30 grams talc (Alphafil™ 500) (Whittaker, Clark & Daniels, Inc., South Plainfield, N.J.), 6.06 g (3.15 g solids) White Dispersion (pigment) (Wamer-Jenkinson, Inc., St. Louis, Mo.), and then 1.05 g triethyl citrate (Morflex, Inc., Greensboro, N.C.). The mixture was then homogenized for 15 minutes or until homogenous. While slowly stirring, the pigment dispersion was added to the “EUDRAGIT™ L 30 D-55” dispersion and then stirred for 30 minutes before spraying. Stirring was also maintained during the spraying process to avoid settling.

The tablets were coated in batches of 50,000 in a Compu-Lab 24 inch/30 L pan with the following settings: 10-20 psi atomizing air pressure; 35° C.-60° C. pan inlet air temperature; 5 to 6 inches nozzle tip to tablet bed distance; and 4/2 baffles/nozzles. After adding the tablets to the pan, the pan was jogged at a speed of 3 to 5 rpm and heated to 40° C. The tablets were then sprayed to a weight gain of 11 to 13% with the following parameters: 27°-33° C. target exhaust temperature (to be achieved within ten minutes of spraying); pan speed of 8 to 12 rpm; 180-240 CFM air flow; and a spray rate of 2-5 g/min/kg. After achieving the desired weight gain, the heat was shut off and the pan jogged at 3-5 rpm until the tablets were cooled to below 30° C.

The tablets were encapsulated in size AA opaque Swedish orange colored DB gelatin capsules (Capsugel, Greenwood, S.C.).

500 mg tablets were also produced as described above, except that coating was done on batches of 25,000 tablets to a weight gain of 8 to 10%.

Example 2 Isolation of Directly Compressible Proanthocyanidin Polymer Composition

A directly compressible proanthocyanidin polymer composition (used to prepare the formulations in Examples 1E and 1F above) was isolated from the latex of the Croton lechleri plant as follows:

460 liters of Croton lechleri latex was mixed with 940 liters purified water for ten minutes and then allowed to stand overnight (12 hours) at 4° C. The red supernatant was pumped into a holding tank and the residue discarded. The supernatant was then extracted with 200 liters n-butanol by mixing for ten minutes and then allowing the phases to separate. The n-butanol phase was discarded, and the aqueous phase was extracted two more times with 200 liters n-butanol each time. After extraction, the aqueous phase was concentrated by ultrafiltration using a 1 kD cut-off membrane (a low protein binding cellulose membrane), and then the retentate was dried in a tray dryer at approximately 37° C. (±2° C.).

For purification by column chromatography, 6 kg of the dried extract was dissolved in 75 liters of purified water and stirred for 90 minutes. The dissolved material was chromatographed on a two column chromatography system consisting of a 35 liter CM-Sepharose column (a weak cation exchange resin) and a 70 liter LH-20 column (a size-exclusion resin) connected in series. The material was loaded onto the CM-Sepharose column, washed with 140 liters purified water, and then eluted onto the LH-20 column with 375 liters of 30% acetone. At this point, the two columns were disconnected, and the proanthocyanidin polymer composition was eluted from the LH-20 column with 250 liters of 45% liters acetone. Fractions were collected into 10 liter bottles and monitored with a UV detector at 460 nm. Fractions containing material having detectable absorbance at 460 nm were pooled and concentrated by ultrafiltration using a 1 kD cut-off membrane (a low protein binding cellulose membrane). The retentate was dried using a rotary evaporator in a waterbath at approximately 37° C. (±2° C.).

The proanthocyanidin polymer composition was tested for direct compressibility. 250 mg portions of the proanthocyanidin polymer composition, in the absence of any binders or excipients, was placed into a tableting machine and then pressed into tablets of varying thicknesses (i.e., the greater the pressure on the composition to form it into a tablet, the thinner the resulting tablet). The hardness of the tablets was then determined in a conventional hardness tester. The friability of tablets having a hardness of 8-15 kp was determined as described in USP 23 <1216>. The friability was less than 0.5% loss in weight.

Example 3 Components, Composition, and Manufacturing of a Drug Product

3A. Drug Product

The drug product, crofelemer, consists of an enteric-coated 125 mg tablet(s) over-encapsulated in a Size 00, opaque Swedish orange gelatin capsule and backfilled with microcrystalline cellulose. Each capsule contains 1, 2, or 4 enteric-coated tablets. The tablet core consists of 99.93% crofelemer and 0.07% magnesium stearate and is coated with a methacrylic acid copolymer.

3B. Components of Drug Product

Crofelemer is supplied by Napo Pharmaceuticals, Inc., and is manufactured under current Good Manufacturing Practices (cGMP). Magnesium stearate is manufactured by Mallinckrodt (or equivalent) and meets the specifications for magnesium stearate as described in 27 USP/NF. The magnesium stearate is certified by the manufacturer to be derived from vegetable sources. Microcrystalline cellulose is manufactured by FMC (or equivalent) and meets the specifications for microcrystalline cellulose as described in 27 USP/NF. Both high-density and low-density microcrystalline cellulose are employed. Methacrylic acid copolymer is manufactured by DeGussa under the trade name Eudragit® (L30-D55) and meets the specifications for methacrylic acid copolymer, Type C, as described in 27 USP/NF. Triethyl citrate is manufactured by Morflex (or equivalent) and meets the specifications for triethyl citrate as described in 27 USP/NF. Talc is manufactured by Whittaker, Clark and Daniels (or equivalent) and meets the specifications for talc as described in 27 USP/NF. Purified water is supplied by the drug product manufacturer and meets the specifications for purified water as described in 27 USP/NF. Swedish orange opaque, Size 00, hard gelatin capsule bodies and caps are supplied by Capsugel, Inc. (Greenwood, S.C.). The manufacturer certifies that the capsules are made from gelatins that meet the current National Formulary (NF) requirements for gelatin under cGMP.

3C. Composition of Drug Product

The composition of the tablet cores and the enteric-coated tablets is described in Table 2 and Table 3, respectively. The amount of crofelemer and magnesium stearate is adjusted based on the anhydrous potency of the drug substance, which corrects for the moisture content of the crofelemer. The amount of weight gain after coating is approximately 10%. The clinical batch size ranges from 100,000 to 150,000 enteric-coated tablets. Subsequently, 1, 2, or 4 enteric-coated tablets are placed in a Size 00 capsule and backfilled with microcrystalline cellulose to match weights of each capsule strength and placebo.

TABLE 2 Composition of Drug Product 125 mg Tablet Cores Theoretical Quantitative mg/unit Ingredient Grade Purpose Compositio dose Crofelemer cGMP Active 99.93%   125 mg Magnesium stearate 27 USP/ Lubricant  0.07%  0.13 mg NF Total   100% 125.13 mg

TABLE 3 Composition of Drug Product Enteric-Coated 125 mg Tablets Theoretical Quantitative mg/unit Ingredient Grade Purpose Compositio dose Crofelemer cGMP Active 90.0% 125.13 mg tablet Eudragit 27 USP/ Coating 7.4% 34.5 mg (10.4 mg L-30 D55 NF solids) Triethyl 27 USP/ Plasticizer 0.8% 1.05 mg citrate NF Talc 27 USP/ Dispersing 1.8% 2.6 mg NF Purified 27 USP/ Solvent N/A* 21.9 mg water* NF Total 100% 136.4 mg *Purified water is removed during process.

3D. Method of Manufacturing the Drug Product

I. Manufacture of Tablet Core

A sufficient amount of crofelemer and magnesium stearate, based on the potency of crofelemer, on an anhydrous basis that adjusts for the amount of moisture, is staged prior to manufacture. Crofelemer is added to the blender and magnesium stearate is screened and added to the crofelemer. The crofelemer and magnesium stearate are blended, a representative blend sample is taken, and the yield is determined. Yield must be between 100±3%. Blend uniformity is not determined, except as needed, because the blend is 99.9% active. The blend is directly compressed on a rotary tablet press, using ¼ inch round concave punches. Finished tablet cores are de-dusted and placed in a container to await coating. Prior to the start of the manufacturing run, pre-production runs are performed to adjust the speed and compression of the press in order to meet the targeted tablet-core weight, thickness, and hardness. In addition, friability and disintegration are measured. During the manufacturing run, tablet-core samples are taken at periodic intervals to ensure that the tablets continue to meet the targeted tablet weight, thickness, and hardness. Representative tablet cores are taken during the beginning, middle, and end of the production run for additional testing for hardness, thickness, weight, friability, and disintegration. The average tablet-core weight must be within ±5% of the targeted tablet-core weight. The number of tablet cores, sample tablet cores, tablet-core waste, and blend waste are reconciled and the percent accountability calculated. The percent accountability must not be less than 95% and not more than 103%. A schematic of the tablet core manufacturing process is presented below.

Schematic of Tablet Core Manufacturing Process

II. Coating of Tablet Core

The amount of Eudragit®, triethyl citrate, talc, and purified water is calculated and staged based on a nominal tablet-core weight gain of 10%. Purified water is charged into a suitable container equipped with a high-shear mixer. The triethyl citrate and talc are added to the container and mixed until homogenized. In a separate container equipped with a propeller mixer, the Eudragit® dispersion is charged and mixed. The triethyl citrate and talc dispersion is added to the Eudragit® dispersion and is continuously stirred throughout the spraying process. The pan-coater machine parameters are adjusted as appropriate and the lines are charged with the coating dispersion. The tablet cores are charged in a coating pan and warmed to 35 to 40° C. while jogging the coating pan. Once at temperature, the average weight of the tablet cores is recorded and the targeted coated tablet weight is calculated. Subsequently, the tablet cores are sprayed and periodically weight-checked until the targeted weight gain is met. The targeted spray rate (4 to 8 g/min/kg of tablet cores), the targeted exhaust temperature (35 to 40° C.), and inlet temperature are monitored at frequent intervals. The tablets are cured for 30 minutes at 45 to 50° C., and then cooled. Representative enteric-coated samples are taken for testing. The average enteric-coated tablet weight must be within ±5% of the targeted enteric-coated tablet weight.

The weight of enteric-coated tablets, enteric-coated tablet samples, and theoretical quantity of enteric-coated tablets are determined and the percent accountable yield calculated. The percent accountable yield must not be less than 95% and not more than 103%. The tablet-core spray-coating process is illustrated below.

Schematic of Tablet-Core Spray-Coating Process

III. Manufacture of Over-Encapsulated Enteric-Coated Tablets

The enteric-coated tablets and microcrystalline cellulose are staged separately for the over-encapsulation of each capsule strength. The amount of microcrystalline cellulose to be encapsulated is calculated in order to achieve a nominal 600 to 800 mg capsule weight, dependent upon the exact dosage form (125 mg, 250 mg, or 500 mg). The average weight of the capsules is calculated based on an average of 100 capsules. The capsules are filled using a semi-automatic over-encapsulation machine fitted with Size 00 change parts and adjusted to deliver the proper amount of tablets and microcrystalline cellulose. Pre-production runs are performed in order to adjust the tray fill weight, the number of turns on the tamper, and the number of times tamped in order to meet the targeted gross capsule weight (capsule shell plus tablets and microcrystalline cellulose). Each tray is prepared by placing the capsule bodies in the capsule tray. Each capsule body is filled with the targeted amount of tablets and microcrystalline cellulose to achieve the targeted fill. The caps are placed on the bodies and closed. The capsules are removed from the tray and de-dusted. A composite of capsules from each tray is collected and weighed for in-process and release testing. The average capsule weight is within ±5% of the targeted capsule weight. The process is then repeated until the desired number of capsules is filled. Damaged capsules, enteric-coated tablet waste, and microcrystalline cellulose waste are collected for final product reconciliation. A composite of the finished capsules is sent for release testing. The number of finished capsules, sample capsules, damaged capsules, and drug substance waste are reconciled and the percent accountability is calculated. The percent accountability must not be less than 95% and not more than 103%. A schematic of the over-encapsulation of the enteric-coated tablets is presented below.

Schematic of Over-Encapsulation of Enteric-Coated Tablets

Example 4 Effect of Enterically Coated Proanthocyanidin Polymer Composition on Patients Suffering from Diarrhea Predominant Irritable Bowel Syndrome

4A. Treatment

The study was a 16-week, multi-center, Phase 2, randomized, double-blind, placebo controlled study in subjects with diarrhea predominant irritable bowel syndrome (d-IBS). Two-hundred and forty-six (246) subjects, meeting the definition of d-IBS as supported by the Rome II Criteria for the Diagnosis of IBS were randomized into four groups: placebo, 125 mg bid, 250 mg bid, and 500 mg bid. The study consisted of a 2-week treatment-free screening period, a 12-week blinded treatment period, followed by a 2-week treatment-free follow-up period.

During the 2-week screening period, subjects self-reported daily information about the status of their d-IBS symptoms via a touch-tone telephone diary. This included information about abdominal pain and discomfort, stool frequency, consistency and urgency. If the subject continued to meet the inclusion criteria at the end of the screening period, and the information captured in the diary during the screening period indicated they had active d-IBS [mean daily stool frequency ≧2; pain score ≧1; stool consistency ≧3 (5-point Lickert scale for pain and consistency)], subjects were randomized into one of four groups according to a computer-generated central randomization schema.

During the 12-week double-blind treatment period, subjects continued to record daily and weekly assessments via a touch-tone telephone diary system as instructed. Subjects were seen every 4 weeks during the treatment period for study assessment visits at which time they received additional study medication.

During the 2-week treatment-free follow-up period, subjects continued to record daily and weekly assessments.

Results:

There were no drug-related serious adverse events. Adverse event rates were similar across all dose groups as shown in Table 4. There were no drug- or dose-related differences in constipation.

TABLE 4 Summary of Adverse Events¹ 125 mg 250 mg Placebo bid bid 500 mg bid No. Subjects/Group 61 62 59 62 No. Subjects with ≧1 AE 14 12 15 15 No of GI AEs 7 10 10 10 GI Event Abdominal distention 0 1 0 1 Abdominal pain 1 2 1 2 Abdominal tenderness 0 0 1 0 Constipation 1 3 2 1 Diarrhea 1 2 1 0 Dry mouth 0 0 0 2 Eructation 0 0 0 1 Flatulence 1 1 3 1 Haematochezia 0 0 1 0 Hemorrhoids 0 1 0 0 Nausea 3 0 1 1 Urgency 0 0 0 1 No. of Other AEs 11 12 15 14 Other Events (>1 AE/group) Dizziness 1 0 3 0 Headache 2 2 1 3 Anxiety 2 0 0 1 Insomnia 0 0 2 1 Rash 1 2 0 0 ¹possible, probably, or likely related.

In general, crofelemer 125 mg bid, as shown in Table 5 exhibited a consistent response among most efficacy endpoints in females. There appeared to be little efficacy in males; however, group size was too small (13-16/group) to analyze separately. Since crofelemer produced no constipation, stool consistency scores approached normal and were not different from placebo. In all other endpoints (frequency, urgency, adequate relief, and pain), there was an improvement in activity with each successive month and during the 2 week treatment-free follow-up period symptoms began approaching baseline levels as expected. Crofelemer 500 mg bid also had a statistically significant effect on pain (0.48 decrease in pain score; 22.44% increase in pain free days). There were 5 female disease outliers (they had >9 stools/day at baseline and were >3 standard deviations from the mean stool frequency of all randomized female subjects) that were not representative of the d-IBS population used in this study and were removed from all analyses presented in this summary.

As shown in Table 6, crofelemer at 250 mg and 500 mg bid had less of an effect on frequency and consistency than the placebo group. Subjects treated with crofelemer 500 mg bid had a greater than half of stool per day mean increase in stool frequency as compared to placebo; there mean stool consistency was 0.22 points higher (closer to loose consistency) as compared to placebo.

TABLE 5 Efficacy of Crofelemer 125 mg bid in Females Endpoint (Δ from Placebo) Results¹ Consistency Score −0.03 Frequency (stools/day) −0.7 Urgency Free Days  11.2% Pain score −0.42* Pain Free Days  12.76%* Adequate Relief   16% ¹Month 3 results; observed case analysis with disease outliers (mean baseline frequency >9 stools/day) removed from all groups. *statistically significant at p < 0.05

TABLE 6 The Effects of Crofelemer 250 and 500 mg bid on stool consistency and frequency Endpoint (Δ from Placebo) 250 mg bid¹ 500 mg bid¹ Consistency Score 0.19 0.22 Frequency (stools/day) 0.24 0.60 ¹Month 3 results; observed case analysis with disease outliers (mean baseline frequency >9 stools/day) removed from all groups.

As seen in FIG. 4, female subjects treated with crofelemer 125 mg bid had a clinically significant decrease in stool frequency. Use of crofelemer led to a decrease of greater than one bowel movement per day. The month-to-month improvement in stool frequency was contrasted by the placebo effect diminishing at month two as values began to approach baseline. When the treatment-free period began at the end of month three, the subjects stopped taking crofelemer and the effect began to go away as expected.

As seen in FIG. 5, crofelemer produced an increase in urgency free days. At Month 3, there was a 35.1% increase in urgency free days in the crofelemer group versus a 23.9% increase in urgency free days observed in the placebo group. There was a month-to-month improvement, as commonly seen. The placebo effect peaked at month two and abruptly decreased as values begin to approach baseline. When the treatment-free period began at the end of month three, the subjects stopped taking crofelemer and the effect began to go away as expected.

As seen in FIG. 6, administration of crofelemer produced an increase in the percentage of subjects reporting adequate relief of d-IBS symptoms. Since d-IBS is comprised of a group of symptoms, the adequate relief endpoint is an overall assessment by the patient as to how well the treatment is addressing their d-IBS symptoms. Crofelemer at 125 mg bid caused a 16% increase in the adequate relief of d-IBS symptoms as compared to the placebo group. With the observed analysis, there was a month-to-month improvement in activity of crofelemer, i.e., the longer the patient took crofelemer, the greater relief of symptoms. As previously seen with other endpoints, the placebo effect peaked at month two and decreased thereafter.

Diarrhea-predominant IBS is differentiated from many functional bowel diseases by the close association of pain with changes in bowel habits. As defined by the Rome II Criteria for the Diagnosis of IBS, pain must be associated with abnormal bowel habits and the improvement of the bowel habits should be associated with the improvement of pain. In this study we have measured pain score with a 5-point scale, where 0 is none and 5 is severe; and the presence of pain free days. As shown in FIG. 4 and FIG. 5, female subjects treated with crofelemer (125 and 500 mg bid) had clinically and statistically significant (p<0.05) decreases in both pain score and pain free days. The effect is quite consistent as observed in the weekly pain score results shown in FIG. 6. This effect on pain relief was unexpected and surprising.

In conclusion, crofelemer at 125 mg bid, was safe and its administration resulted in improvement in the efficacy endpoints of pain, adequate relief, frequency, and urgency in female subjects. Crofelemer at 250 and 500 mg bid was safe and, compared to placebo, appeared to worsen the diarrheal symptoms of consistency and frequency. Crofelemer at 125 and 500 mg bid produced a statistically significant decrease in both pain score and pain free days in female subjects with d-IBS.

Example 5 Investigation of Crofelemer Mechanism of Action

To further investigate the mechanism of action of crofelemer, crofelemer at 10 and 100 μg/mL was evaluated in a selected panel of cellular cytokine release assays (IL-1α; TNF-α-induced and IL-1-induced PGE2 release; IFN-γ; IL-2, IL-4; IL-5; IL-6; IL-8; IL-10 and TNF-α) and molecular assays (COX-1 and COX-2 enzyme assays, and glucocorticoid, serotonin 5HT3, δ-opiod, κ-opiond, μ-opiod, and non-selective opiod receptor binding assays. Crofelemer was also tested in cytotoxicity assays corresponding to the ConA- and LPS-induced cytokine release assays as well as those corresponding to the TNF-α- and IL-1-induced PGE release assays.

Crofelemer exhibited significant (>50%) inhibition in the IFN-γ; IL-2, IL-4; IL-6; IL-8; IL-10 and TNF-α cytokine release assays as well as in the TNF-α-induced and IL-1-induced PGE2 release assays at 10 and 100 μg/mL (i.e., all cytokine release assays with the exception of IL-5). Crofelemer also displayed significant cytotoxic activity in the ConA and IL-1-induced PGE2 cytotoxicity assays suggesting that in the ConA-mediated cytokine release assays (IFN-γ, IL-2, IL-4 and IL-10) and the IL-1-induced PGE2 release assay may be due to general cytotoxicity.

Further, at both 10 and 100 μg/mL, crofelemer caused a 73% and 100% inhibition in the COX1 and COX2 enzyme assays, respectively.

Many modifications and variations of this invention can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. The specific embodiments described herein are offered by way of example only, and the invention is to be limited only by the terms of the appended claims, along with the full scope of equivalents to which such claims are entitled. Such modifications are intended to fall within the scope of the appended claims.

All references, patent and non-patent, cited herein are incorporated herein by reference in their entireties and for all purposes to the same extent as if each individual publication or patent or patent application was specifically and individually indicated to be incorporated by reference in its entirety for all purposes. 

1. A method of treating pain and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain and diarrhea associated with d-IBS.
 2. A method of treating abdominal discomfort and diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort and diarrhea associated with d-IBS.
 3. A method of treating pain associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat pain associated with d-IBS.
 4. A method of treating abdominal discomfort associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat abdominal discomfort associated with d-IBS.
 5. The method of any one of claims 1 to 4, in which the inhibitor is an extract from Croton spp. or Calophyllum spp.
 6. The method of any one of claims 1 to 4, in which the inhibitor is latex from Croton spp. or Calophyllum spp.
 7. The method of any one of claims 1 to 4, in which the inhibitor is an inhibitor of CFTR function.
 8. The method of claim 7, in which the inhibitor of CFTR function is selected from the group consisting of 2-thioxo-4-thiazolidinone compounds and 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl) methylene]-2-thioxo-4-thiazolidinone, tolbutamide, glibenclamide and fluorescein or a derivative thereof, diazoxide, lemakalim, minoxidil sulfate and analogs thereof; 8-bromo-cAMP, 8-(4-chlorophenylthio) (CPT)-cAMP and 8-bromo-cGMP, CPT-cGMP; verapamil, nifedipine, diltiazem, disulfonic stilbene compounds, diphenylamine-2-carboxylate (DPC) or 5-nitro-2(3-phenylpropylamino)benzoate (NPPB); anthracene-9-carboxylic acid (9-AC); 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl)methylene]-2-thioxo-4-thiazolidinone; N-(2-naphthalenyl)-[(3,5-dibromo-2,4-dihydroxyphenyl)methylene]glycinehydrazide (GlyH-101) or derivatives thereof; malonic acid dihydrazides or derivatives thereof; loperamide; racecadotril; lidamidine hydrochloride; lonidamine; vanadate; bumetanide; pp2a; PP1; PP2B; bismuth subsalicylate; diphenoxylate hydrochloride; and sparteine.
 9. The method of any one of claims 1 to 4, in which the inhibitor is a synthetic or naturally-occurring polymer composition.
 10. The method of claim 9, in which the polymer composition comprises at least one monomer selected from the group consisting of catechin, epicatechin, gallocatechin and epigallocatechin.
 11. The method of any one of claims 1 to 4, in which the inhibitor is a proanthocyanidin polymer composition.
 12. The method of claim 11, in which the polymer composition is isolated from a Croton species or a Calophyllum species.
 13. The method of any one of claims 1 to 4, in which the inhibitor is crofelemer.
 14. The method of claim 13, in which crofelemer enteric coated and is orally administered in an amount of between about 50 mg per day and about 750 mg per day.
 15. The method of claim 14, in which crofelemer is administered in an amount of about 250 mg per day.
 16. The method of any one of claims 1 to 4, in which pain- or discomfort-free days increased by at least 10%.
 17. The method of any one of claims 1 to 4, in which the inhibitor is not systemically absorbed.
 18. A method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the diarrhea associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer.
 19. A method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a molecule that inhibits secretion of chloride ions from a cell (inhibitor molecule) effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, with the proviso that the inhibitor molecule is not a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. or that the inhibitor molecule is not crofelemer.
 20. The method of claim 18 or 19, in which the method further comprises administering an analgesic agent or an anti-inflammatory agent.
 21. The method of any one of claims 18 to 20, in which the inhibitor is a small molecule inhibitor of CFTR.
 22. The method of any one of claims 18 to 20, in which the inhibitor is an isolated naturally occurring inhibitor of CFTR, or a synthetic or semisynthetic form of a naturally occurring inhibitor of CFTR.
 23. The method of claim 21, in which the small molecule inhibitor of CFTR is selected from the group consisting of: 2-thioxo-4-thiazolidinone compounds and 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl) methylene]-2-thioxo-4-thiazolidinone, tolbutamide, glibenclamide and fluorescein or a derivative thereof, diazoxide, lemakalim, minoxidil sulfate and analogs thereof; 8-bromo-cAMP, 8-(4-chlorophenylthio) (CPT)-cAMP and 8-bromo-cGMP, CPT-cGMP; verapamil, nifedipine, diltiazem, disulfonic stilbene compounds, diphenylamine-2-carboxylate (DPC) or 5-nitro-2(3-phenylpropylamino)benzoate (NPPB); anthracene-9-carboxylic acid (9-AC); 3-[(3-trifluoromethy)phenyl]-5-[(3-carboxyphenyl)methylene]-2-thioxo-4-thiazolidinone; N-(2-naphthalenyl)-[(3,5-dibromo-2,4-dihydroxyphenyl)methylene]glycine hydrazide (GlyH-101) or derivatives thereof; malonic acid dihydrazides or derivatives thereof; loperamide; racecadotril; lidamidine hydrochloride; lonidamine; vanadate; bumetanide; pp2a; PP1; PP2B; bismuth subsalicylate; diphenoxylate hydrochloride; and sparteine.
 24. The method of claim 22, in which the inhibitor is selected from arachidonic acid; linoleic acid;oleic acid, elaidic acid, palmitic acid, myristic acid, lysophosphatidic acid, and niflumic acid; flavonoids, flavonols, polyphenols, proanthocyanidins, oligomeric proanthocyanidins, (OPCs), procyanidolic oligomers(PCOs), condensed tannins, leukocynanidins, anthocyanidins, procyanidins, cyanidins, prodelphinidins, delphinidin, catechins, epicatechins, gallocatechins, epigallocatechins, epigallocatechin gallate, epicatechin gallate, catechin gallate, gallocatechin gallate, quercetin, sesquiterpenes, diterpenes, terpenes, and terpenoid derivatives, tannins, alkaloids, saponins, morin, and luteolin.
 25. A method of treating diarrhea associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer (CAS 148465-45-6) effective to treat the diarrhea associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day.
 26. A method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of enterically-protected crofelemer effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is between about 50 mg per day and about 750 mg per day.
 27. A method of treating diarrhea associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of crofelemer (CAS 148465-45-6) effective to treat the diarrhea associated with d-IBS, in which the crofelemer is formulated to be protected from the stomach in a formulation other than enteric coated, said amount bioequivalent to enteric-coated crofelemer at a dosage of about 50 mg per day to about 750 mg per day.
 28. A method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising orally administering to a patient in need of such treatment, an amount of crofelemer effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which the crofelemer is formulated to be protected from the stomach in a formulation other than enteric-coated, said amount bioequivalent to enteric-coated crofelemer at a dosage of about 50 mg per day to about 750 mg per day.
 29. A method of treating diarrhea associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the diarrhea associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer.
 30. A method of treating abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS comprising administering to a patient in need of such treatment, an amount of a polymeric proanthocyanidin composition isolated from Croton spp. or Calophyllum spp. effective to treat the abnormal stool frequency, abnormal stool consistency or presence of urgency associated with d-IBS, in which said amount is bioequivalent to an orally administered dose of about 50 mg per day to about 750 mg per day of crofelemer.
 31. The method of any one of claims 1-4, 18, 19 or 25-30, in which the patient is a human female. 